Anna Lembke, MD on The Neuroscience of Addiction, Dopamine Fasting & The Opioid Crisis

The relentless pursuit of pleasure always leads to pain. As the world evolves from one of scarcity to overabundance, we increasingly orient our lives around the pursuit of pleasure and avoidance of pain—an instinct that has produced a myriad of unprecedented types of addiction, and consequently, the pain we so desperately seek to avoid. To better understand this conundrum, I’m joined today by one of the world’s leading authorities on the neuroscience of addiction, Anna Lembke, MD. If that name sounds familiar, it’s likely due to her on screen presence in the Netflix documentary The Social Dilemma—a must-watch for anyone with a smartphone. Anna is a professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is widely published, has testified before Congress, and has authored two important books, Drug Dealer MD and her newest work, Dopamine Nation—a powerful primer on compulsive overconsumption in a world where feeling good has become confused with the highest good. This is an important and impactful conversation that explores: The nature, psychology, and neuroscience of addiction; the explosion in addiction in lockstep with technological advances; the opioid crisis & the fascinating history behind how we think about and treat pain; recovery protocols from 12-step & the latest science on psychedelic treatments; and how to manage & avoid addiction. To read more click here. You can also watch listen to our exchange on YouTube. And as always, the podcast streams wild and free on Apple Podcasts and Spotify. Whip-smart and radically empathetic. I can’t underestimate the importance of Dr. Lembke’s work, and this conversation is a must listen for any and all who suffer from some form of addictive compulsivity, or know someone who does (which is pretty much everyone). Enjoy! Peace + Plants, Rich Learn more about your ad choices. Visit podcastchoices.com/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Rich Roll?

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• 1:05Anna Lembke?

  For so long, we've had this idea that addiction is a downstream consequence of some other problem, but addiction is its own problem. You can have a perfect life and get very, very addicted. Because, yes, it's true that childhood trauma increases your risk for developing addiction. Yes, it's true that addiction leads to isolation and that the antidote to addiction is social connection in part. But what is so important to understand is you can have the perfect childhood, the perfect parents, the greatest social network, the best spouse, wonderful kids, and you can get really, really addicted.

• 1:46Anna Lembke?

  And that is so important for people to understand, and also healthcare providers, because everybody's sort of looking for the reason behind the addiction, but there doesn't have to be a reason behind addiction. Addiction just can be on its own. We live in a world in which we are saturated with dopamine, and we live in a culture which encourages us to pursue it. But the ultimate end result of pursuing dopamine is to feel worse than when you started. And this is really the central message.

• 2:19Anna Lembke?

  People are more depressed, more anxious, more suicidal, and more addicted than they were 30 years ago. And I contend that one of the main reasons is because of this relentless pursuit of pleasure that essentially adjusts the dopamine levels, changes the hedonic pleasure set point to make people anhedonic, meaning without joy.

• 2:44Rich Roll?

  That's Dr. Anna Lembke, and this is the Rich Roll Podcast.

• 2:59Rich Roll?

  The Rich Roll Podcast. We're going to talk about addiction today. Substance addiction, of course, but also addiction more broadly. How, as the world has evolved from one of scarcity to one of overabundance, and we increasingly orient our lives around the pursuit of pleasure and the avoidance of pain, how we set ourselves up for myriad and unprecedented types of addiction, and consequently invite the pain into our lives that we so desperately seek to avoid. My guest for this exploration is Dr. Anna Lembke. Anna is a professor of psychiatry at Stanford University School of Medicine and chief of

• 3:44Rich Roll?

  the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar and authority on addiction medicine, the neuroscience of addiction, and the opioid crisis, Anna has appeared in the Netflix documentary Social Dilemma, widely discussed on this podcast. She is widely published, she's testified before Congress, and has authored two important books. Drug Dealer MD, which The New York Times declared one of the top five books to read to understand the opioid epidemic, and her newest, Dopamine Nation, which is a really

• 4:23Rich Roll?

  powerful primer on how to moderate compulsive overconsumption in a world where, unfortunately, feeling good has become confused with the highest good. A few more things to mention before we dive in, but first.

• 4:47Rich Roll?

  Okay, Dr. Anna Lembke. This is an important conversation, an impactful conversation that explores the nature, psychology, and neuroscience of addiction, the explosion in addiction that is occurring in lockstep with technological advances. We talk about the opioid crisis and the fascinating history behind how we think about and treat pain. We discuss a variety of recovery protocols, from 12-step to the latest science on psychedelics, and what to do to avoid becoming addicted and what to do if you become addicted.

• 5:27Rich Roll?

  It's a conversation that I think will reframe and broaden your understanding of addiction, and I suspect will hold great value for anyone currently struggling with addiction or close to someone who does, which, let's face it, is almost everybody. So, without further ado, this is me and Dr. Anna Lembke. Anna, so nice to meet you. Thank you so much for traveling down here to do this. I really appreciate it.

• 5:59Anna Lembke?

  Well, you're very welcome. I'm really excited to be here.

• 6:02Rich Roll?

  Yeah, I'm excited to talk to you. We were introduced by our mutual friend, Andrew Huberman. Any recommendation from him is one worth noting. He's such an unbelievable mind. He's been a great guest, and he's become a good friend. And upon his recommendation, the more I've dug into your story and your work, the more excited I got to do this with you. I think you're really the perfect person to have a really, I think, important impactful conversation around the nature of addiction and kind of the current culture and our relationship to the dopamine-induced world that we now find ourselves in.

• 6:45Anna Lembke?

  Well, first let me say I agree with you 100% on Andrew Huberman. He is my colleague at Stanford, another professor, but I've seldom met a colleague who so generously was willing to promote someone else's work. And he's been just amazing about Dopamine Nation and trying to help me get the word out and get it read. And of course, I'm really, really excited to be here and talk to you. It's a real privilege.

• 7:14Rich Roll?

  Yeah, yeah, yeah. I mean, so much to talk about. People who listen or watch the show know that I have a personal history with addiction and recovery and sobriety. It's a major theme or topic that recurs on this show. And I think a good place to kind of start with this is to share a little bit, from my personal perspective, when I think back on my emotional state of being when I was at the nadir of my using and facing the prospect of getting sober, I just remember such a deep sense of shame and embarrassment and this sense of just being irreparably broken

• 7:57Rich Roll?

  and being scared of everybody, scared of everything of the world. And this sense that really getting honest with myself about the fact that I was an addict really equated to just to being a broken human being. And this pathology that it evokes, because my sense was that addicts were needle fiends and hopeless drunks, and that's kind of where the conversation begins and ends. But as somebody who's been steeped in the recovery community and somebody who's been sober for a little while, I've become increasingly convinced over many years that addiction

• 8:36Rich Roll?

  is so misunderstood and so much more widely prevalent than I think we realize. And also that it exists on a spectrum that is so broad that it's not that much of a stretch to argue or contend that on some level...

• 8:55Rich Roll?

  We can all identify ourselves somewhere along that spectrum, whether it's a mild unhealthy compulsion, all the way to some kind of full-blown life implosion. And I'm interested in your sense of that because I feel that your work, and in particular, this latest book, Dopamine Nation, which we're going to talk about, really is furthering that sensibility and providing that kind of perspective to a broad audience.

• 9:26Anna Lembke?

  I want to first respond to your use of the word feeling broken. I think that is probably the single most powerful thing that has drawn me to people with addiction in recovery, is that they've passed through that crucible of complete feelings of brokenness, humility, and they've come out the other side as these incredible humans with tremendous wisdom. And the book really is in homage to people with addiction who have found recovery, precisely because they have a profound humility

• 10:10Anna Lembke?

  having been through that experience. And although my addictions, which I talk about in the book, are more minor than somebody with severe addiction.

• 10:21Rich Roll?

  And somewhat comical.

• 10:23Anna Lembke?

  Somewhat comical. But from me, they were actually...

• 10:26Rich Roll?

  Real for you. It's a subjective relationship.

• 10:29Anna Lembke?

  It is. And because of the work that I do, I was at some point able to be aware of what was happening to me that I don't think I would have been able to do had I not been in the line of work that I am. But I think, most importantly, I've had other experiences in my life that have left me also feeling totally broken, a broken human, full of shame, full of feeling like I wasn't good enough. And so I've really gravitated toward other people who have... Had that experience of brokenness and yet from it becomes stronger because of

• 11:09Anna Lembke?

  the profound humility that it engenders and a kind of surrender to the universe and a willingness to appreciate that, like, we have so little control and all the other stuff, all the other good stuff that comes with that.

• 11:25Rich Roll?

  Yeah, you share a quote near the beginning of the book that I love by this guy Kent Dunington, who says, "Persons with severe addictions are among those contemporary prophets that we ignore to our own demise for they show us who we truly are."

• 11:39Anna Lembke?

  Yes, and that's who I'm meeting for dinner.

• 11:41Rich Roll?

  Oh, you are, cool. Who is Kent Dunning? I don't know who he is.

• 11:44Anna Lembke?

  So, he's a really interesting guy. He's a theologian and a philosopher. He works at Viola University. And I first came across a book he wrote called Addiction and Virtue, which is this philosophical lens through which to consider whether or not addiction really is a disease and whether or not people have a choice and what that choice looks like. And he uses Aristotle. And it's a fascinating look at that question because in the medical field now, I am really steeped in this idea that addiction is a disease. It's a chronic relapsing and remitting disease. There's, you know, verifiable brain chemistry changes that occurs. People become addicted. And yet, and yet, and I believe that that's true,

• 12:29Anna Lembke?

  and yet, there is this element of choice, right? Somewhere along the way, people can choose to get help. Really, that's the fundamental choice piece that's left. They can't necessarily choose to not drink or not use, but they can choose to say, "I don't have the ability to choose or not choose to drink, but I do have the ability to hand it over to somebody else who might help me."

• 12:54Rich Roll?

  Sure.

• 12:55Anna Lembke?

  So, anyway.

• 12:56Rich Roll?

  But that element of choice is difficult. You know, often, it's said that recovery is for people who want it, not those who need it. And too often, the person who needs it is unable to make that choice. They're like the most unlikely person to make that choice.

• 13:16Anna Lembke?

  Yes, yes. I think that's right. That's right. I mean, and that's where this kind of mysterious thing happens, where even people who really don't have the ability to make the choice. Can get into recovery, right? And we see that happen all the time.

• 13:33Rich Roll?

  Right. And so, you know, in the context of this, we're going to talk about neuroscience. We're going to talk about psychology. We're going to talk about environment, genetics. There are so many things that contribute to this. But in that context of choice, it's so, it never ceases to astound me that some people can just have an epiphany and say, this is a problem and I'm going to correct it. And they just do it while others have to go to the gates of hell before they're ready to reckon with it. And too many just perish, you know, without ever having the courage to, you know, make that switch.

• 14:10Anna Lembke?

  Yes, that's right.

• 14:11Rich Roll?

  It's so terrifying and sad in that regard, right?

• 14:16Anna Lembke?

  Yes.

• 14:17Rich Roll?

  But my perspective is that in the typical case is the person who is kind of sliding down that scale with their addiction until they get to the point where the pain of perpetuating or continuing along that path exceeds the fear of letting go of it and trying something new.

• 14:37Anna Lembke?

  Yeah, that's right. That recognition that there's really no other option but to embrace recovery.

• 14:45Rich Roll?

  So why don't we define our terms here a little bit?

• 14:49Anna Lembke?

  Okay, yeah.

• 14:50Rich Roll?

  Like, how do you define addiction?

• 14:52Anna Lembke?

  I define addiction as the continued compulsive use of a drug or behavior despite harm to self and/or others. How do you define it?

• 15:04Rich Roll?

  I mean, that's the standard definition, yeah.

• 15:07Anna Lembke?

  Yeah, right.

• 15:08Rich Roll?

  And how does that, like, as I mentioned at the opening, there's alcoholism, there's drug addiction. There are some qualitative differences between substance addiction and behavioral addictions. And now that we're in this world where everything has an addictive allure to it, do you qualify our relationship with our devices and online shopping and gambling in the same way? Like, with this idea of addiction being a spectrum, how does it differ in terms of, like, our relationship to Twitter versus our relationship to heroin?

• 15:44Anna Lembke?

  I don't really see all that much difference between those things. I think it's just a matter of degree. Obviously, when we're talking about heroin, we're talking about the physiologic dependence and withdrawal as well, which I do think happens with behavioral addictions to things like Twitter. I believe we can have a true physiologic dependence and withdrawal to those behaviors, but not to the same degree as with something like an opioid. But in terms of the psychological aspect of the attachment, I think it's very, very similar. And I believe that because I've seen so many people come through my office who are addicted to things like gaming, gambling, pornography, shopping.

• 16:28Anna Lembke?

  And the natural history is exactly the same. The manifestations are the same. The process of getting into recovery is the same. So to me, they're all one bucket.

• 16:38Rich Roll?

  So is there a distinction between kind of an unhealthy, recurring, semi-compulsive habit and what you would consider truly an addiction?

• 16:48Anna Lembke?

  Because both habits and addictive behaviors work through our dopamine reward pathway, I really think it's the same biology. It's just a matter of degree. And because I have seen people who can get severely addicted to behaviors like gambling, pornography, video games, to the point where they are suicidal, so their life is threatened by that disease process or that behavior, I really think it's the same biochemistry. It's the same phenomenon in the brain.

• 17:24Rich Roll?

  Yeah. It seems to me we're in this weird time where, on the one hand, we use the word addiction very cavalierly, like, oh, I'm addicted to my TV show, or chocolate, or what have you. And yet, at the same time, we underappreciate the fact that some of these things truly are addictions, right? Like, these two things kind of cross each other in the night in a weird way, which I think prevents us from really looking at them through the appropriate clinical lens.

• 17:58Anna Lembke?

  Yes, I think you're right. I think... The way that we cavalierly refer to behaviors as addictions, "Oh, I'm addicted to whatever, my Netflix show," does minimize the extent to which the brain biology is the same and also minimizes the impact on our lives. Because if we were to really scrutinize that behavior, I think people would begin to realize that it really, truly does have an adverse impact on their lives and that, you know, we can't trivialize that. I mean, I've had, for example, you know, journalists writing for esteemed publications,

• 18:43Anna Lembke?

  you know, call me to interview me about sex addiction and say to me, "Well, that's, it's not really an addiction, is it? I mean, it's really just about cultural mores around, you know, what's acceptable sexual behavior and what isn't." And I've had to correct that person and say, "No, you're, you're wrong. This is really an addiction. It can devastate lives. People can lose their lives over these problems. And it's not just about, you know, oh, you know, polyamory should be socially accepted. That's, that's not what we're talking about here. We're talking about a compulsive, out-of-control phenomenon that has very serious consequences for people's lives.

• 19:22Rich Roll?

  Sure. If anybody questions that, I encourage you to read the first chapter of your book because it's the most harrowing, bone-chilling story of a sex addict. And the lengths that that guy goes to, to satisfy his need.

• 19:36Anna Lembke?

  Right.

• 19:37Rich Roll?

  It's unbelievable.

• 19:38Anna Lembke?

  Yeah, and the fact that he's highly educated, that he's a good and kind person, that he has good social support, he has a great job. I mean, this is what I really want to drive home to people. Like, yeah, there are many risk factors for addiction, but you can have none of those risk factors in today's world and get really addicted.

• 19:56Rich Roll?

  Mm-hmm. Do you feel like we're starting to understand that? In the sense that anybody can be an addict, regardless of your social status or level of education, et cetera?

• 20:08Anna Lembke?

  I do think so. I mean, I do think we've moved beyond this moralizing around addiction as more and more people struggle with severe addiction and it crosses all demographics, all social classes. I think people... I mean, for example, in surveys of Americans asking whether or not they think addiction is a biologically based disease, the majority of Americans today will say, yes, it is. And that's different from 50 years ago.

• 20:35Rich Roll?

  Yeah.

• 20:35Anna Lembke?

  So I think we have shifted in that regard. But I think what's still new to people is the extent to which we've all become vulnerable to this problem.

• 20:49Rich Roll?

  Yeah, that is a big difference.

• 20:51Anna Lembke?

  Yeah.

• 20:52Rich Roll?

  Right. And I do think, although we may recognize that that truth in that there is this biological component to it, we still are shocked when we hear the story of the upwardly mobile person who goes down some dark rabbit hole. Do you remember that? It was a New York Times article a couple of years ago about the guy, the lawyer in Silicon Valley.

• 21:13Anna Lembke?

  Yes.

• 21:13Rich Roll?

  That was like a huge profile of his second, you know, his other life.

• 21:16Anna Lembke?

  Yes.

• 21:17Rich Roll?

  And I just remember how, you know, people were so shocked by that story. Somebody who's been in recovery for a long time, like, yeah, you know, I hear that story all the time.

• 21:25Anna Lembke?

  Right.

• 21:26Rich Roll?

  But that was, I remember that being a big deal.

• 21:28Anna Lembke?

  Yeah, I think that there's still this kind of self-medication hypothesis thinking around addiction, which is only partially true. And the hypothesis goes like this, that addiction is the result of some other problem, either a willpower problem, or a psychiatric illness problem, or, you know, a sociocultural problem. But you can have none of those problems and still get addicted. And that's what's, like, I've spent a major part of my career reeducating, in particular, psychiatrists around this idea, because for so long, we've had this idea that addiction

• 22:12Anna Lembke?

  is a downstream consequence of some other problem. But addiction is its own problem. You can have a perfect life and get very, very addicted.

• 22:22Rich Roll?

  Yeah, yeah, that's a really important point. You know, I've had... Conversations with Gabor Maté. And for him, it's all about childhood trauma. Resolve that, you resolve the addiction. I had Johann Hari here. For him, it's all about lost connections, your connectivity to your friends and your family and your community. And I think those are important pieces in this puzzle. But I'm reluctant to be reductionist about the role that those play in the broader context of addiction.

• 22:54Anna Lembke?

  Thank you so much for invoking those examples because that shows me that you perfectly understand what I'm trying to communicate here. Because yes, it's true that childhood drama increases your risk for developing addiction. Yes, it's true that addiction leads to isolation and that the antidote to addiction is social connection in part. But what is so important to understand is you can have the perfect childhood, the perfect parents, the greatest social network, the best spouse, wonderful kids, and you can get really, really addicted. And that is so important for people to understand and also healthcare providers

• 23:36Anna Lembke?

  because everybody's sort of looking for the reason behind the addiction. But there doesn't have to be a reason behind addiction. Addiction just can be on its own.

• 23:45Rich Roll?

  Yeah, I think that's a crucial point. I mean, I get asked very frequently, like, what do you think caused this? Like, what is the source of your addiction? And, you know, I'm heavily indoctrinated in 12-step and I'm sure I have some biases around that. But one of the things that you learn is that it's fine if you want to psychoanalyze that aspect of your origin story, but ultimately, it doesn't avail you with the tools for how to live today and how to move productively forward. And You know, there is an argument to be made that it's sort of, you know, fools err and to spend too much time on that.

• 24:23Anna Lembke?

  Yes, insight can be the booby prize.

• 24:26Rich Roll?

  Yeah.

• 24:26Anna Lembke?

  Yeah, no, this is a really very, very important concept. And the other reason it's important is because I think we're natural storytellers and we want to rationalize irrational behavior. And so the first thing that we try to do when we are doing something that's irrational and self and other destructive is to tell ourselves a story or have someone else tell us a story about why we would do that crazy thing.

• 24:53Rich Roll?

  And if we can solve that equation, then suddenly everything makes sense and you can figure this out.

• 24:59Anna Lembke?

  Right.

• 24:59Rich Roll?

  But it doesn't work that way.

• 25:01Anna Lembke?

  No, no, I mean, I have had over 20-plus years countless patients come into my office and say, "Dr. Lembke, the reason that I'm addicted to alcohol or I'm addicted to cannabis or I'm, you know, a compulsive gambler is because I'm depressed and anxious. And if you would just fix that, then I wouldn't have that other problem." And what I have to do is say to them, "You know what? I wish that were true, but here's the truth. Number one, even if I could magically wave my wand and make your depression and anxiety go away, once you're addicted, you're addicted. And if we don't focus on that problem, that's not going to get better." The other thing is that, you know, that relationship between psychological symptoms and addiction, it's complicated.

• 25:44Anna Lembke?

  And it's not necessarily that the depression comes first and then the addiction comes. Addiction can lead to depression and anxiety, which is why my first intervention so often is to have people abstain. But I'll never forget a patient of mine who said, "You know, Dr. Lembke, I realized I was an alcoholic when I got started on an antidepressant. Wasn't depressed anymore, but kept drinking." That was his aha moment because he was like, "Oh, I thought I was drinking because I was depressed, but when I stopped being depressed, I was still drinking."

• 26:13Rich Roll?

  Yeah, that's kind of the genius behind your dual diagnosis clinic, right? It's almost a Trojan horse way of just treating addiction because the way you get them in the door... In a non-threatening way is under the rubric of treating their anxiety or depression, etc.

• 26:29Anna Lembke?

  Right, yes. Although it's not without effort because people are resistant to that idea, right? They come in and they want help with depression, anxiety. They see the addiction as a secondary problem. And it takes all my powers of persuasion to get them on board.

• 26:48Rich Roll?

  Yeah, none too happy to be told that we can't deal with your, you know, conditioned X until we deal with this substance or behavioral addiction that you have. And they storm out and leave a one-star Yelp review or something.

• 27:02Anna Lembke?

  Exactly. You've got it exactly. You understand.

• 27:06Rich Roll?

  Yeah, people don't want to hear that. You know, it's interesting. That piece, I mean, as a psychiatrist, though, you must have honed tools for how to communicate with people to kind of crack that core.

• 27:18Anna Lembke?

  Yes. And the key piece is to be empathic at the same time that you're telling people what they don't want to hear.

• 27:27Rich Roll?

  Mm-hmm.

• 27:27Anna Lembke?

  You know what I mean?

• 27:28Rich Roll?

  That's a tightrope.

• 27:29Anna Lembke?

  It is, it is. But I feel like I've gotten pretty good at it. Having teenagers also helps. You know, the sort of you breathe and you stay calm and you say, you know, I understand what you're saying, right? So the typical sort of validating first. But then you give them kind of the real deal, you know, what the science shows, what my clinical experience shows, what I'm asking them to experiment with so that they can gather their own data and see if what I'm saying is right.

• 27:58Rich Roll?

  But on the data piece, I mean, this doesn't operate, you know, in a logical framework. It's an emotional framework. And timing is so important, right? Like, I'm happy to talk sobriety with anyone who's suffering, but I've learned to detach or from any expectations of what they will or won't do. Like, people get sober when they're ready to.

• 28:18Anna Lembke?

  Yeah. And one of the main things I have to teach my trainees, my fellows, is that An essential part of the work that we do is that we have to actually really care about our patients, but there is a point at which you can care too much. And when we're trying harder than the patient is, or wanting it more than the patient wants it, we're not actually helping them.

• 28:40Rich Roll?

  Then you gotta go to the Al-Anon meeting.

• 28:42Anna Lembke?

  That's right. Well, we have to conduct our own little Al-Anon session, you know, right there at work. Because I work with a bunch of young folks, which I can say is one of the most exciting things that's happened in the last 10 years. You know, 10 years ago, I couldn't find a medical student under a rock who wanted to learn about addiction. Now they're beating down my door, which is really awesome.

• 29:01Rich Roll?

  Yeah. Well, let's talk about the neurochemistry of addiction. Walk me through what's happening in our brains and the role that dopamine plays in all of this.

• 29:11Anna Lembke?

  Yeah, so dopamine is a neurotransmitter, which means that it is the molecule that allows the electrical signal from the presynaptic neuron to be communicated to the postsynaptic neuron, because there's a little gap called the synapse between those two neurons. So neurotransmitters allow fine tuning of those electrical signals. And dopamine is the most important neurotransmitter involved in motivation and reward. And the fundamental difference between things that are addictive and those that aren't is that things that are addictive release a lot more dopamine. So we have dopamine firing in our brain that occurs at a tonic baseline. And when we do something that's rewarding or pleasurable, we get a little rise in dopamine levels or a spike.

• 29:56Anna Lembke?

  So for example, chocolate increases dopamine levels about 50% above baseline. Sex is about 100%. Nicotine is about 150%. And things like methamphetamines are 1,000%, partially because of their specific mechanism. But the fundamental way that I explain to patients and medical students, and now in my book, about the neuroscience of addiction, so that they can really understand what's happening in the brain, is I say that really, you have to imagine that in your brain, there's a balance, like a teeter totter in a playground. When we experience pleasure, the balance tips one way. When we experience pain, it tips the other.

• 30:38Anna Lembke?

  But one of the fundamental rules governing that balance is that it wants to remain level. So with any deviation from neutrality, the brain will work very hard to restore a level balance, or what's called homeostasis. So for example, if I do something pleasurable, like eat a piece of chocolate, I get a little tip to the side of pleasure, a little release of dopamine. But no sooner has that happened than my brain adapts to that phenomenon by down-regulating my own dopamine receptors, down-regulating my own dopamine transmission. And I imagine that as these little gremlins hopping on the pain side of the balance to bring it level again. But the thing about the gremlins is they like it on the balance, so they stay on until the balance is tipped an equal and opposite amount to the side of pain.

• 31:23Anna Lembke?

  And that's called the opponent process reaction, the hangover, the come-down, the after-effect. Now, and in my case, that's that moment of wanting another piece of chocolate. If I wait long enough, the gremlin hops off and balance is restored. But if I continue to consume chocolate in ever larger amounts to overcome the tolerance or the number of gremlins on the pain side, then I end up with enough gremlins on the pain side of my balance to fill this whole room. And I'm essentially in a dopamine deficit state with a balance tilted to the side of pain. Now I have to keep using, not to feel good, but just to feel normal. And when I stop using, my balance tips hard to the side of pain. I'm irritable, I'm depressed, I'm anxious, I can't sleep.

• 32:08Anna Lembke?

  Those are the universal symptoms of withdrawal from any addictive substance. And that can last a long time.

• 32:15Rich Roll?

  Yeah. I think it brings up an important, kind of broader, point about culture in general, and this idea that we live in a situation in which there's this asymmetry in terms of how we approach our lives with respect to pleasure and pain. And we organize our lives completely around the pursuit of pleasure and the avoidance of pain. But as you kind of astutely put in the book, the more that we pursue that, ultimately, the more pain that we reap. Because these systems require a level of homeostasis that we're constantly trying to avoid. So we're just delaying the inevitable onslaught of pain that, you know, we so fear.

• 33:03Anna Lembke?

  Yes, absolutely. We live in a world in which we are saturated with dopamine, and we live in a culture which encourages us to pursue it. But the ultimate end result of pursuing dopamine is to feel worse than when you started. And this is really the central message. People are more depressed, more anxious, more suicidal, and more addicted than they were 30 years ago. And I contend that one of the main reasons is because of this relentless pursuit of pleasure that essentially adjusts the dopamine levels, changes the hedonic or pleasure set point to make people anhedonic, meaning without joy.

• 33:47Rich Roll?

  Yeah, and you can kind of calibrate this in lockstep with how we've progressed from a world of scarcity into a world of overabundance, right? And so, these addictive behaviors and substances are ubiquitous. It used to just be, you know, hard drugs and alcohol and cigarettes, et cetera. But now, it's literally everything from, you know, the billboards and the advertisements and the marketing messages crafted by Madison Avenue to, of course, the devices that we all carry around with us that are specifically designed to lure us into this, you know, dopamine-induced state. And the food system that's specifically designing foods with the right proportion

• 34:33Rich Roll?

  of salt, sugar, and fat to make it impossible to just eat one potato chip.

• 34:38Anna Lembke?

  Yes, exactly. I mean, addiction can happen now in every realm of life. It's almost impossible to escape it. And the three factors that make anything more addictive are quantity, potency, and novelty. And what our capitalist, technologically innovative world has created is an infinite quantity, incredible potency, and endless novelty and variety.

• 35:03Rich Roll?

  And ubiquitous availability.

• 35:05Anna Lembke?

  Yes.

• 35:05Rich Roll?

  Right.

• 35:06Anna Lembke?

  And the smartphone.

• 35:07Rich Roll?

  It's unavoidable.

• 35:07Anna Lembke?

  Yes, right.

• 35:08Rich Roll?

  Now.

• 35:08Anna Lembke?

  And now it's 24/7 and it's digital and it's right to your doorstep. Exactly.

• 35:12Rich Roll?

  Right. Everything's delivered as well.

• 35:13Anna Lembke?

  Yes, right.

• 35:14Rich Roll?

  Including all the substances.

• 35:15Anna Lembke?

  Right.

• 35:16Rich Roll?

  Which we're going to get into. But one curious thing for me is, you know, why someone becomes, if this, you know, dopamine neurotransmitter pathway that you're speaking about seems to be, you know, a general quality of all humans, why do some people get addicted and why some people don't? And, you know, for example, like alcohol is my drug of choice. Gambling, which debilitates a lot of people, carries no charge for me at all. Like, I just couldn't be less interested in it. Like, how does that work? Is that where genetics and nurturing and all kinds of other things come into play?

• 35:53Anna Lembke?

  Well, first, let me speak to the concept of drug of choice because it's a fascinating one and there's actually very little science around it. But we know phenomenologically that it's true. What makes one person's balance tip to the side of pleasure doesn't necessarily make another person's balance tip to the side of pleasure. So for me personally, I thought that I was immune to the problem of addiction because the substances that are readily available and that most people get addicted to do absolutely nothing for me. But look what happened to me. I did find a substance that turned out to be incredibly reinforcing for me, essentially romance novels.

• 36:32Rich Roll?

  Right.

• 36:32Anna Lembke?

  Right. I know, you laugh, you laugh.

• 36:34Rich Roll?

  Yeah.

• 36:35Anna Lembke?

  I mean, you know, it wasn't.

• 36:36Rich Roll?

  Did you really read the entire Twilight series four times?

• 36:39Anna Lembke?

  I did. That was my gateway drug. Are you kidding? I really did. And then I moved on from there because I developed tolerance after the fourth time.

• 36:46Rich Roll?

  It was no longer doing it for you.

• 36:47Anna Lembke?

  It wasn't. It wasn't good enough. It was, and it was really mysterious because I was like, you know, this is like a teenage romance novel about vampires. And I was in my 40s. So, I mean, that in itself is slightly embarrassing, but it just, it just led to this, down this whole weird road for me.

• 37:03Rich Roll?

  Enter 50 Shades of Grey.

• 37:05Anna Lembke?

  Right, right.

• 37:06Rich Roll?

  That'll do the trick.

• 37:07Anna Lembke?

  That was my bottom right there. No pun intended.

• 37:12Anna Lembke?

  So I guess my point, you know, to answer your question is that I think we're all going to get addicted to something because now that special key that works for each of our individual locks, it's out there somewhere and the world wide web will allow us to find it. Having said that, it is true that people bring different degrees of vulnerability to the process of addiction. We do know that about 50 to 60% of the risk of becoming addicted is genetic. That's based on family studies showing that if you have a biological parent or grandparent addicted to alcohol, you are at increased risk of becoming an alcoholic yourself, even if you're raised outside of the alcoholic home in a non-using home.

• 37:56Anna Lembke?

  So that's powerful genetics. It's polygenic, it's complex, we don't fully understand it. It's thought to be related to things like impulse control, ability to delay gratification, emotional dysregulation, but you know, we don't really know what it is. Other risk factors include co-occurring psychiatric disorders. People with psychiatric disorders are more likely to develop an addiction. And also how you were raised. If you had a traumatic experience, as we've talked about, that puts you at risk. If you have parents who have explicitly or implicitly condoned substance use, either for recreation or as a coping strategy, that puts you at risk. Things like poverty, unemployment, that puts you at risk.

• 38:38Anna Lembke?

  So there are lots and lots of risk factors, but I think that the major risk factor in the modern world, and one which is generally ignored, is simple access. If you have access to a drug, you are more likely to try it and more likely to get addicted to it. And now, as we've talked about, we live in a world of virtually infinite access.

• 38:57Rich Roll?

  Yeah, you say, there's a quote in the book, something along the lines of, whatever, there is something that will addict you and it's coming to a website near you soon.

• 39:06Anna Lembke?

  Right, right.

• 39:07Rich Roll?

  Yeah, and it's never, it's never been more true. But that idea that there is a drug out there that will be the key to your specific lock, I think is super interesting. And you use the example in the book of this Stanford student who had all manner of problems and kept screwing his life up and... Tried all different kinds of drugs and would come back to Stanford and just go down some crazy drug rabbit hole and drop out. And he did this a number of times until he was prescribed Suboxone and that really kind of balanced him out. And then the question becomes, is this something that he, you know, in his mind, he's like, I need to do this for the rest of my life. Like, I can function as a normal human being right now.

• 39:49Rich Roll?

  The question being, can he be, you know, titrated off of that and be normal? Or is there truth to this idea that some people have a brain chemistry that's lacking in some regard that a substance can solve to make them productive and, you know, quote unquote, kind of normally operative?

• 40:09Anna Lembke?

  Yes. I'm so glad that you have fundamentally understood that example of this very wonderful young man who is still my patient. And he is doing so well in his life. It's just great to see. And he's a great guy. And as you describe, I don't know the answer. You know, I don't know whether he was born with something missing, whether his heroin use broke his brain so that now he needs the opioids for the rest of his life, whether maybe it's really something with our culture and, you know, our inability to create community,

• 40:49Anna Lembke?

  which he looked for at Stanford and couldn't find, and that somehow the opioid then becomes a way to adapt to a crazy world. And maybe that's okay. Like, maybe we have to take drugs to like, just exist in this really nutty world. You know, all those questions are things that I don't have the answers to, but that I think a lot about.

• 41:09Rich Roll?

  Yeah, it's complicated, isn't it?

• 41:12Anna Lembke?

  Yeah.

• 41:13Rich Roll?

  You know, I mean, the addict in me wants to believe that there's some drug out there that will solve my sense of discomfort, you know, and will allow me to just be functional without any kind of pathology attached to it.

• 41:26Anna Lembke?

  Well, here's what I've come to conclude, and this is really a mantra for my own life, that I'm never actually going to feel comfortable in the world or with living, that it's always going to be painful and unpleasant, and that's just the way it is.

• 41:40Rich Roll?

  Well, that's back to the pain-pleasure kind of paradox, right? I mean, that's that's sort of a page out of Susan David's thesis of developing emotional resilience, like just being okay with the fact that, you know, in this happiness-obsessed world that we live in, you know, acknowledging the truth that life is hard, and the more that we can kind of just be present with that, the more resilience we develop and the more kind of productive and fulfilled we ultimately can become. But people don't want to hear that.

• 42:13Anna Lembke?

  You know, it's really fascinating. So as I've matured as a psychiatrist, and as I've just matured, I will say to patients things like, they'll say, you know what, I'm not, you know, life is really hard, or I'm just anxious all the time, and I will say things like, yeah, I know what you mean, me too. And you would be surprised, but people are kind of relieved. They're kind of relieved. They're sort of like, wow, if this Stanford doctor is like experiencing anxiety and dysphoria and discomfort, like, maybe that's okay. I mean, maybe that's that's all right for me then, too.

• 42:56Anna Lembke?

  So by kind of having shared suffering, I think it makes the suffering more bearable. But also, I really think we need to recalibrate our expectations. I know that that part of my role as a psychiatrist is to re-educate patients about what they should really be expecting from their lives.

• 43:16Rich Roll?

  Yeah, I feel like that that sort of burst the bubble. You know, every addict thinks that their interior experience is wholly unique, and that nobody can relate to it, and their problems are just so off the rails. And that leads to the shame and the embarrassment and the inability to kind of connect with another human being and be honest about what that behavior is.

• 43:38Anna Lembke?

  Yes, yeah, the terminal.

• 43:40Rich Roll?

  I mean, the amount of courage that that sex addict guy had to summon to be so open with you about what he was actually doing is tremendous.

• 43:49Anna Lembke?

  I know. And that's why my patients are my heroes.

• 43:52Rich Roll?

  Yeah, it's crazy.

• 43:54Anna Lembke?

  I mean, what he has had to overcome in his life and what the discipline required every single day for him to stay into recovery, that's incredible.

• 44:04Rich Roll?

  Right, it's superhuman.

• 44:05Anna Lembke?

  It is superhuman.

• 44:06Rich Roll?

  Yeah, and also, you know, not for nothing, like, the level of creativity and craftiness and resourcefulness that the addict, the lengths that the addict will go to, to fill that need, I mean, in that guy's case, it's like, it's unbelievable, right? Like, if you can just get that person healthy and find a healthy outlet for that level of concentrated, you know, energy.

• 44:28Anna Lembke?

  Yeah.

• 44:29Rich Roll?

  It's, you know, it's a powerful thing.

• 44:31Anna Lembke?

  Well, kind of like what you did with your life, right? You took that energy and you channeled it into a whole new way of being, which is a really high standard in your life, right? You have to exert, I mean, maybe it's not, I shouldn't assume it requires discipline, but, you know, you've chosen a path that is not easy in terms of your diet and your fitness and all of that. It's a, I don't know, you tell me, but it's...

• 44:56Rich Roll?

  Yeah, well, you know, I guess what, the way I would characterize it is, I work hard on my recovery, I have plenty of character defects, my alcoholism manifests itself in all manner of, you know, errant behaviors. But I've made peace with the fact that my disposition is, you know, attracted to extremes, and I've tried to find healthy outlets for that. You know, people are always, "Oh, you just transferred your alcoholism onto ultra endurance events," or "You have an eating disorder because you have this restrictive diet." And, you know, I'll acknowledge that there's truth in all of those things. Whether those are addictive relationships, I'm not quite so sure, because they have moved my life forward.

• 45:41Anna Lembke?

  Right.

• 45:42Rich Roll?

  Like, they haven't, they haven't created those negative consequences that my, you know, my alcohol use did.

• 45:48Anna Lembke?

  Right. Yes, and you know, you, your personality structure, I'm assuming, but this is sort of my job. You know, you have an intensity to you and your intensity has to find an outlet. And you have to find a healthy and adaptive one.

• 46:05Rich Roll?

  Sure.

• 46:05Anna Lembke?

  And you have.

• 46:06Rich Roll?

  And it's dopamine inducing.

• 46:08Anna Lembke?

  That's right.

• 46:09Rich Roll?

  You know, for sure.

• 46:09Anna Lembke?

  That's right.

• 46:10Rich Roll?

  You know, and as somebody who makes their living online, like, I'm not immune from, ooh, how many people listen to that? Or how many, you know, what kind of response did this podcast get? Or that Instagram post get?

• 46:21Anna Lembke?

  Right.

• 46:21Rich Roll?

  And I have to be really careful around that.

• 46:23Anna Lembke?

  Yes, you do. And you have to like, probably do your inventory and be like, am I okay with this? And what's driving this? And what, you know, what kind of needs are coming up?

• 46:33Rich Roll?

  Yeah.

• 46:34Anna Lembke?

  I mean, sometimes people ask me, well, I've seen people who get into recovery through 12 steps, Alcoholics Anonymous. It's like they just, it's a cult and they just get addicted to Alcoholics Anonymous. And I'm like, so?

• 46:44Rich Roll?

  Fine.

• 46:44Anna Lembke?

  Yeah, right. Like, I mean, did you see their life before and their life after? It's like, pretty good now, right? So who cares?

• 46:53Rich Roll?

  Yeah, it's interesting.

• 47:02Rich Roll?

  On that piece of 12 step, you know, like I said at the beginning, I'm very indoctrinated in that. It's saved my life. It continues to save my life. It's, you know, the priority of, you know, of my life to stay sober and help another alcoholic achieve sobriety. You know, my, my friends, my community are all, you know, part of this. And I find myself, you know, kind of confronting the fact that every year, there's somebody who comes up with some new homespun, you know, way of getting sober and staying sober. And everything you thought you knew about AA is wrong. And now we have enter stage left psychedelic, you know, protocols for treating addiction

• 47:45Rich Roll?

  and other mental health disorders, et cetera. And, you know, it's always, I'm constantly being, I always go back to AA and 12 step. And I have a challenged relationship with my openness to those other things because I know it's worked for me. So I'm curious about how you think about the recovery context and the kind of protocols that are available to us.

• 48:10Anna Lembke?

  To me, AA is one of the most remarkable social movements of the past 100 years. When I have a patient who comes into my office who's been in recovery through 12 steps or is thinking about recovery through 12 steps, I'm like, hallelujah, because those patients are easier to manage and get better and stay better longer. So I think it's a remarkable movement. There is so much wisdom there. As I write about in my book, I try to really elucidate what the neuroscience behind some of the things that AA has been teaching for 100 years. Like, I have a whole chapter on truth telling and why it's so important to tell the truth

• 48:51Anna Lembke?

  and what is the neuroscience possibly behind why truth telling allows us to be in recovery and to manage our compulsive overconsumption. So I think it's a remarkable organization. I think there's divine wisdom in it. And I think that a bunch of the AA bashing that's happened in the last 10, 15 years is just misinformed and misguided. You know, a Cochrane review recently came out that really looked at the scientific evidence behind AA, and there's also good science to support it. So it's not just that my clinical experience tells me that it works and your personal experience, but if you look at the data, I mean, people who actively engage in AA and

• 49:34Anna Lembke?

  other 12 steps do better, longer, even than people who get some kind of professional therapy.

• 49:40Rich Roll?

  Yeah, I feel like it's sort of lazy and easy to just take shots at it and say, "Well, I tried it, it wasn't for me." Well, did you try it? Like, what did you actually do?

• 49:51Anna Lembke?

  Well, and I think it's important to acknowledge that it's not the path for everyone, right? It's not the path for everyone. But that doesn't mean that it's like, not a good path, right? That doesn't mean that somehow you throw the whole thing out the window just because it didn't work for you or you had a bad experience. And then, of course, I absolutely agree with you. And when people say they've tried it in the past and it didn't work, I'm always like, "Well, try it again." You know, this might be, this might be the time that it really takes. And for my most severely addicted patients, it's almost...

• 50:22Anna Lembke?

  Universally, the best option. And the data support that for the more severely addicted, 12 steps may actually work better than anything else.

• 50:33Rich Roll?

  People get tripped up on the God part.

• 50:35Anna Lembke?

  Yes, they do. Yeah.

• 50:36Rich Roll?

  So I'm interested in, as a neuroscientist, as a psychiatrist, how do you conceptualize the role of spirituality in all of this? Because it is such a core precept, tenet of 12-step.

• 50:51Anna Lembke?

  And I think that gets back to how we started, where you talked about just feeling totally broken. To me, that is the fundamental spiritual pivot. When we acknowledge our brokenness, that is when we can give it over to something outside of ourselves. And that can take many different forms. But the key piece there is acknowledging that we are not in control. And that when we ask the universe, such as it were, you know, to guide us or help us, that simple reorientation totally changes, like, decision-making. It changes so many things about how we proceed in our lives.

• 51:36Anna Lembke?

  The sort of, you know, cognitive math of decision-making or what to do next. And I know I've experienced that for other reasons, not related to addiction. And I know that's the fundamental pivot that my patients experience, that kind of feeling utterly broken and then looking outside themselves, something larger than themselves, in order to pick those pieces up again and move on.

• 52:02Rich Roll?

  Yeah, that idea of surrender and the kind of humility that ensues with that is a tall mountain to climb for a lot of people. And it was difficult for me, but that's really where things kind of open up and you are able to reframe your relationship with how you're living.

• 52:20Anna Lembke?

  Yes, right. It's a total game changer, really, when you make that pivot. And it's amazing, the good things that come from doing that.

• 52:31Rich Roll?

  Yeah. Let's talk about withdrawal a little bit. Back to the biochemistry of everything. Obviously, you know, every substance has a different half-life and the withdrawal from... Whatever you're doing is going to be different. But what's going on in your brain? You talked about the kind of seesaw and the way that dopamine operates. When somebody is withdrawing from a substance and they're kind of experiencing the pain that comes with that, what is going on? And what does it take to kind of get past that to the other side?

• 53:08Anna Lembke?

  So there's a distinction between acute withdrawal and protracted withdrawal. Acute withdrawal is essentially where the body manifests the opposite of whatever the drug does. So if you have been using a stimulant, then in acute withdrawal, you will be sedated. If you've been using a sedative, then in acute withdrawal, you will have physiologic restlessness. And that can last anywhere between a few days to a few weeks, depending upon the substance and its half-life, as you point out. But once you get through the acute physiologic withdrawal, I think what's underappreciated generally is that there can be this sustained protracted withdrawal that can go on for

• 53:50Anna Lembke?

  months and in some cases even years, which is primarily psychological symptoms. Again, irritability, anxiety, depression and insomnia, as well as craving. So this is like ruminative obsessive thinking about wanting to use. And that can even be accompanied by sudden physiologic feelings, sweating, stomach cramps. But that's the piece that I, in my mind, I visualize the pleasure-pain balance chronically weighted to the side of pain because those neuro-adaptation gremlins have essentially camped out there. They like it there and they're not getting off. And that is what drives relapse, even after people's lives have gotten objectively better,

• 54:35Anna Lembke?

  right? They've gotten their spouse back, their job back. And yet, and then people see them relapse and they say, well, why would they do that? Everything was going so well. But if you put yourself in the mind of that person, what you would see is that every day they get up, they are anxious, they are irritable, they are craving. And that is what drives relapse. It's sort of that intense physiologic and psychological suffering, really.

• 55:00Rich Roll?

  Yeah, after the acute withdrawal, that protracted period where everything just feels gray.

• 55:06Anna Lembke?

  Yes.

• 55:06Rich Roll?

  Because you're so used to those dopamine hits. And even though your life is getting better, in the back of your mind, you're just like, if I just do this one thing, like, I'll be able to write that paper or get through this uncomfortable experience. And I'm just gonna do it once. And that's the cunning, baffling, and powerful component here that mystifies the non-addict. Because it leaves them just utterly confused as to why somebody would make that choice. But it's almost impossible to avoid.

• 55:39Anna Lembke?

  Yes.

• 55:40Rich Roll?

  Depending upon the behavior and the substance, obviously, some are more powerful than others.

• 55:44Anna Lembke?

  And what I've come to appreciate is that something strange happens to our perception of time when we're in that state. So we're in that state of craving and dysphoria. It really feels like it will never end. I mean, it will. You know, in most cases, we know with sustained abstinence, the gremlins hop off, homeostasis is restored. But when we are in that state, it feels as if it will go on forever. Plus, as you said, we have a way to fix it, right? It's right there within reach. If we use again, we can relieve those feelings. So I think that's the combination of those things, the distorted time perception, that those awful feelings will never end, even though they will,

• 56:26Anna Lembke?

  and knowing that we can make ourselves feel better if we just use.

• 56:30Rich Roll?

  Yeah, and if you're telling the patient they're facing the prospect of possibly years of this.

• 56:35Anna Lembke?

  Right.

• 56:36Rich Roll?

  I mean, if they're coming off benzos or something like that, they're in for a very long, hard road.

• 56:41Anna Lembke?

  Yes, that's right. Fortunately, in my experience, most people who abstain for one month begin to notice improvements in mood, hopefulness, you know, sleep. They might not be where they want to be, but they begin to see a little bit of light at the end of the tunnel. Not always, but that's the piece that then I really have to remind them of. And I say, remember how you felt when, you know? And if you can just hang in there with recovery and with abstinence, you know... Incrementally in small ways, you will get better. And I think that's an important function that I serve. Kind of a cheerleader and a reminder, because the hippocampus is tricky. I also think that's a major function of AA, right?

• 57:24Anna Lembke?

  That we go, I use the we pronoun. So I'm not a member of AA, but in my clinical work, I use the we pronoun because, again, I think we're all broken and humbled in the face of this problem. So I'll say to patients, remember how you felt then. Remember how you felt a little bit better. You've done this before. You know, you remember, you have the data from recovery. Hold that close and tincture of time alone will get you there.

• 57:50Rich Roll?

  Are there cases where that dopamine balance never again reaches some level of homeostasis?

• 57:58Anna Lembke?

  Yeah, so unfortunately, I think that that can happen. So, for example, in the book, I think the case of Chris, possibly one of the things that happened to him was after so many years of opioids.

• 58:09Rich Roll?

  Suboxone.

• 58:10Anna Lembke?

  Yeah, that the only way, that his balance was essentially broken. It was stuck tilted to the side of pain. And the only way for him to feel normal is to be on, you know, what's called replacement therapy or opioid agonist therapy in the form of suboxone, which has sustained him feeling well now going on almost a decade. And I'm talking very, you know, he's doing great. It's not like he's just kind of trudging along. He's doing great.

• 58:37Rich Roll?

  And he's been able to maintain that, that, that level of suboxone at a base rate? Like he's not asking for more, you know?

• 58:45Anna Lembke?

  No, and I do see that. I do have patients for whom, for reasons we don't understand, they do seem to develop tolerance, but not him. It worked immediately. It worked well. It restored homeostasis. He's re-engaged with life. And he's interesting, at least, somebody who never went to 12-step and never really got a whole lot of psychotherapy beyond, you know, what we do. But that's what works for him.

• 59:09Rich Roll?

  Yeah, so interesting. I'm always amazed with, by people who just figure out how to get sober and stay sober without AA. And, you know, I've often thought, what happens if someone like yourself develops some kind of pill that resolves, you know, alcoholism addiction on a biochemical level? Like, would I take it? And I wouldn't, I wouldn't trade my experiences or the richness of my life experience and what I get out of this. Program in this community for that option.

• 59:40Anna Lembke?

  Yeah, that's so cool. And I've heard that from so many of my patients that they get to a point in their recovery where they actually regard their disease of addiction as a gift.

• 59:49Rich Roll?

  Yeah, I remember when I first came in and you would hear, you know, there's always the guy who says, I'm a grateful alcoholic.

• 59:55Anna Lembke?

  Yeah, right.

• 59:56Rich Roll?

  How fucking asshole is that?

• 1:00:00Rich Roll?

  What are you like, how, what, what? You know, I didn't understand it. And now, of course, I completely understand that.

• 1:00:06Anna Lembke?

  Yeah.

• 1:00:06Rich Roll?

  And that goes back to this, this idea of embracing the painful parts of life and understanding that those are our greatest teachers. And if you can really learn about yourself through those experiences, you can create meaning around them that can be helpful for other people as well.

• 1:00:24Anna Lembke?

  Yeah, I mean, as a physician, you know, one of the things that attracted me to addiction medicine, in addition to the patients themselves, was the docs in recovery who practice addiction medicine, because they're not like any other types of doctors. You know, when I go to medical meetings that are not addiction focused, everybody's like trying to show off how much they know more than the other guy. And then you go to, you know, an addiction medicine conference and people are like, yeah, you know, I'm X number of years in recovery and, oh, man, I'm struggling with this character defect and that character defect and I'm so embarrassed by this or that or another thing I did. It's just such a cool culture.

• 1:01:01Rich Roll?

  Yeah, and it's empowering.

• 1:01:02Anna Lembke?

  Yeah.

• 1:01:03Rich Roll?

  I never get tired of hearing the stories. And I'm sure when people read your book, they're going to be so shocked to read these. But I'm so inculcated in that, like, I'm so used to hearing the craziest stories and I love it. I love the honesty and the vulnerability of all of it. And it's so empowering and it's such a beautiful expression of our shared humanity.

• 1:01:23Anna Lembke?

  Yes, wonderfully put. You know, when I, when I first wrote the book and I gave it to my agent and the editor, they were like, you know, this story of sex addiction, like, maybe you could put it toward the middle or, you know, at the back.

• 1:01:41Rich Roll?

  You're just blasting people from page one.

• 1:01:44Anna Lembke?

  Like, they were really, they were really worried that it just people. People would just be so freaked out, it would be so other that it just that nobody would read it. And I'm like, you know what? I'm not going to do that because this is exactly the point that I'm trying to make. Like pornography and sex addiction, it is everywhere. I mean, we are not, we're not being truthful with ourselves. If we are pretending like this is not a huge problem, this is a huge problem and we need to put it up front and center. Now, the book is not just about sex addiction, it's about all kinds of addictions. But like you, I hear these stories every day. So to me, there's, they're not freaky and other. And, and, and in the book, I really relate my patient to my own kind of sex addiction that I developed. And, and I wanted to do that, you know?

• 1:02:29Anna Lembke?

  As you said, I wanted to make sure that people understand like this is all of us, right? I mean, this is our shared humanity, as, as you said.

• 1:02:37Rich Roll?

  Yeah, yeah, I mean, a lot of people will remember you from The Social Dilemma. You appeared in that documentary. And that's a beautiful, you know, starting point to have this conversation about the universality of all of this, whether it's sex addiction, or online shopping, or porn, or gambling, or, you know, Twitch streaming. It doesn't matter, like, it's so ubiquitous. And on some level, we're all addicts, or we're all addicts in waiting.

• 1:03:10Anna Lembke?

  Right.

• 1:03:11Rich Roll?

  Right? And, and so, you know, I thought it was interesting that in this book, you know, there's nothing on the cover. There's, the word addiction is not used on the cover. Like, this is not a book for addicts to read. This is a book for everybody to read because I think it's important that we reframe how we think about addiction and all of the levers and, and pulleys and buttons that are out there right now just waiting to trigger us and lure us into unhealthy relationships.

• 1:03:39Anna Lembke?

  Yes.

• 1:03:39Rich Roll?

  With substances and things and behaviors and everything, all of it out there.

• 1:03:43Anna Lembke?

  Yes, yep, yep, you, you get it exactly.

• 1:03:47Rich Roll?

  So elaborate, I guess. I don't know, that wasn't really a question. But you know, this, this idea that we are all addicts, I think is revelatory for, and I think people will, will, will, that may ruffle some feathers, like, I'm not that.

• 1:04:01Anna Lembke?

  Yeah.

• 1:04:02Rich Roll?

  I just know, even when I was in the depths of alcoholism, I would always look at people who were worse than me to say that I'm not this.

• 1:04:09Anna Lembke?

  Right.

• 1:04:09Rich Roll?

  As opposed to looking for ways to identify or find similarities.

• 1:04:14Anna Lembke?

  Yeah. I mean, if you look at the, the basic wiring of the brain, we are all wired to approach pleasure and avoid pain. And that is what has kept us alive in a world of scarcity for, you know, gazillions of years. And the fundamental problem now is that we are not living in that world of scarcity. We live in this world of overwhelming abundance, but our, you know, our brain chemistry and our wiring hasn't changed. So when you are basically wired to seek out pleasure and avoid pain, and you live in a world surrounded by pleasure goods, infinitely available at the tap of a finger, and you're encouraged to avoid pain at all costs, you know, how could we not get addicted?

• 1:04:54Anna Lembke?

  Of, of course, we, we are and we will. And I do think people are beginning to relate to that, especially as regards smartphones and things that we're doing online, because people are now observing their own behavior, getting, you know, losing time, getting caught up, spending way more time than they planned, having it interfere with, you know, their, their parenting or their work or, so I do think that there, I hope that there is sort of this dawning awareness that this is a universal phenomenon. And that, yes, we're variably vulnerable, which is to say, we're not all equally gonna, you know, become addicted, but that we are all vulnerable to the fundamental problem now.

• 1:05:36Rich Roll?

  And that we're essentially outgunned and outmatched.

• 1:05:40Anna Lembke?

  Yeah.

• 1:05:40Rich Roll?

  You know, that was a big point in the documentary, that you think that you have some agency here.

• 1:05:45Anna Lembke?

  Right.

• 1:05:46Rich Roll?

  Well, think again, because you have no idea how much money and science has gone into removing that agency

• 1:05:52Anna Lembke?

  That's right.

• 1:05:52Rich Roll?

  when it comes to your relationship with your devices.

• 1:05:54Anna Lembke?

  Yes, exactly. And also in importantly, and this is again, something I learned from my patients. When we are in our addictions, we cannot see the true consequences of those behaviors. It's, I mean, you know, in the world of addiction, it's called denial. But I mean, it's really a fascinating phenomenon how we cannot objectively observe ourselves or the consequences of these compulsive behaviors until we get some distance from it and look back and then kind of go, wow, that was surreal that I did that much of that thing for that long. Like, that was really bizarre. And I also lied about it and like, you know, did all these like fancy maneuvers to do it more. And now I look back and it's like, I mean, I've had so many of my patients say, it's like another person. It's like that was

• 1:06:38Anna Lembke?

  another person, you know, which is very interesting.

• 1:06:42Rich Roll?

  Yeah. Why did I sit on the toilet for an hour staring at my phone? You know?

• 1:06:49Anna Lembke?

  There are a lot of teenagers out there spending a lot of time in the bathrooms these days. I can tell you that.

• 1:06:54Rich Roll?

  Listen, I've done it. Like, I'll call myself out right now on that. When you were talking about the doctors that are your colleagues that are in recovery, it reminded me of my experience in treatment. I went to a treatment center where there was a lot of professionals there on diversion. So a lot of doctors and a lot of pilots, like the two people that you literally give all of your agency over to. It's very horrifying to realize that surgeons and anesthesiologists and commercial airline pilots were in treatment. And I wanted to share anonymously some of those stories when I was writing Finding Ultra. And my publisher said the same thing. They're like, it's too

• 1:07:35Rich Roll?

  crazy. You can't do that. But to hear these, you know, tales from anesthesiologists like stealing fentanyl and how it made them more productive and leads to ketamine and jumping off roofs and all kinds of crazy stuff. Like, there was a doctor who was taking just handfuls of Vicodin every day. There was another neurosurgeon who was a IV morphine addict. Like, you know, it's wild.

• 1:08:01Anna Lembke?

  You know, being smart and being highly educated is not any protection against addiction. It might even make you more vulnerable because you think that you'll know.

• 1:08:11Rich Roll?

  You're a Superman.

• 1:08:12Anna Lembke?

  Yeah, or that you'll know when you've crossed the line. I mean, you know, I've had, I've treated many docs in addiction over the years, but the one that comes to mind now is an anesthesiologist, you know, who had just a big stash of pills and he would, you know, take them in all different combinations and permutations. And he just thought, well, I'm an anesthesiologist.

• 1:08:29Rich Roll?

  Right.

• 1:08:30Anna Lembke?

  You know, so I know how to dose this stuff. Until he didn't, you know what I mean?

• 1:08:34Rich Roll?

  There's got to be a higher percentage of anesthesiologists that become addicts versus other doctors.

• 1:08:38Anna Lembke?

  Yes, higher percentage of anesthesiologists and psychiatrists.

• 1:08:43Rich Roll?

  Hmm, why psychiatrists?

• 1:08:45Anna Lembke?

  Oh, you know, we're kind of stuck in our heads.

• 1:08:47Rich Roll?

  Is it the brokenness that allures you into the profession to begin with?

• 1:08:52Anna Lembke?

  I think it's the kind of, I mean, I would be, I wouldn't want to speak for all psychiatrists, but I don't know. I don't know what it is. I mean, many people who go into psychiatry have family members with mental illness. And so there's kind of a mission-driven purpose, wanting to help others. Sometimes it's, you know, being broken and wanting to help yourself. But I think that's become less and less true as the field has attracted a lot of very high-powered students who are really into neuroscience and such. I don't know, I don't know what it is. I mean, with anesthesiologists, you know, the assumption is it because of increased access to things like opioids and benzos. But I think there's probably a self-selection process where you've got people who are already maybe addicted or vulnerable

• 1:09:36Anna Lembke?

  or almost addicted, who then subconsciously choose anesthesia because maybe because of the access. I don't know.

• 1:09:42Rich Roll?

  Yeah. Yeah, in anesthesiology, you're just dealing with those all the time. And I hear these crazies, like you get these tiny little vials of fentanyl and they would like take a little bit of it and fill the rest of it with water and the lengths that they would go to be undetected and tapping into the...

• 1:10:03Rich Roll?

  The pharma closet.

• 1:10:04Anna Lembke?

  But you know, I mean, doctors are just regular people, right? With all the same regular problems. I mean, in some ways, what's so tragic about about doctors and addiction and the problems of getting into recovery when you're in that profession is because I think the shame is more pronounced because you're supposed to be this healer who's got it all together. One of the things that was kind of scary for me in writing Dopamine Nation was that obviously I disclose, you know, ways that I'm kind of messed up. So, I mean, that that has brought up a lot of shame for me and kind of worrying what other people will think. It is fascinating how afraid we are to do that. I think everybody's afraid to do that, but I wonder if physicians are maybe a little more afraid.

• 1:10:49Rich Roll?

  Yeah, yeah, I would suspect that that's true. But there has to be a cathartic aspect to that for you as well, right? A freeing.

• 1:10:59Anna Lembke?

  Yes, absolutely. I mean, I really try to live a transparent life where everything I say and do, if it were published on the front page of a major newspaper, I would be OK with it. And so it's not really maybe as much of a leap for me to disclose those things as it would be for, you know, somebody in another field of medicine or somebody with a different past than I've had. But, you know, I mean, I've never read a doctor authored book where they're nothing but the most wonderful healer. Do you know what I mean?

• 1:11:29Rich Roll?

  Right, right. And that leaves you distrustful.

• 1:11:31Anna Lembke?

  Yeah.

• 1:11:32Rich Roll?

  There's something about leading with vulnerability and the honesty, you know, incumbent in that that leads me to feel like this person has more integrity. It works, it works counterintuitively to the way you think it might.

• 1:11:44Anna Lembke?

  Yes, well, I'm glad to hear that, and I agree with you. And in my own psychiatric practice, I've really changed the way that I view disclosure. So we're, we are trained to not disclose anything about ourselves, to be sort of that removed Freudian type of person who You know, listens empathically and strategizes with the patient about how to get well, but doesn't actually disclose our own thing. But I'm not sure I believe that anymore. First of all, I mean, our patients can see through us. We bring ourselves to the practice. But also, I think that it's helpful for patients to know that, like, we're all broken, you know, and we all struggle. And so I try to do it thoughtfully. I'm like, I'm not like airing my dirty laundry with my patients, you know, going on and on

• 1:12:29Anna Lembke?

  about my problems. But I do strategically talk about my own anxiety, you know, my own depression, my own insomnia, my own sense of life being, you know, kind of a drudgery at times.

• 1:12:43Rich Roll?

  That is interesting, yeah, because you think of a therapeutic context as you're this blank slate, right? Who never once, you know, gives any clue as to what you think or who you are.

• 1:12:55Anna Lembke?

  Right. Right. And it's so funny because the expressions on my patients' faces, like when I do that, initially, there's sort of like this raised eyebrow, like, get me out of here. Get me out of here. This lady's crazy.

• 1:13:06Rich Roll?

  Or like, this is about me, not you.

• 1:13:08Anna Lembke?

  Right. No, I don't get that so much because I don't go on and on. But there's this sort of like, there's initially this alarm, it's like, I don't want to be treated by a crazy psychiatrist. But then I think on some core level, they recognize that, well, maybe she's, you know, not that crazy, and maybe there's a reason that she's telling me that. Although I did have this one patient who was telling me about his flying phobia, and I'm like, oh, yeah, I get that. And then he goes, well, and I like to sit next to the window because I feel like if I can see the ground somehow, that makes it less likely that we're actually going to fall. And I'm like, I'm right with you there. I always get the window seat. And that's when he was like, crazy. But he came back. He came back, and he managed to get off his benzodiazepine. So it was a success story.

• 1:13:50Rich Roll?

  Where are we in terms of the number of people that qualify as being addicted? Maybe specifically to substances right now? Like, it's on the rise, right? There's a crazy spike in the percentage of people that are dealing with some form of substance addiction.

• 1:14:07Anna Lembke?

  Yeah. So, I mean, here's a crazy statistic. Fifty percent of the world's deaths attributable to addiction occur, well, fifty percent of the world's deaths are attributable to addiction in those under age fifty. So, I mean, that's a whole lot of people, right? If we've got more than half of the world's deaths due to addiction in people under fifty, that's kind of scary. And then if you look at specifically things like alcohol, so rates of alcohol have gone up in the last twenty years, including in groups that were previously immune to alcohol addiction. Rates of alcohol use disorder or alcohol addiction have gone up fifty percent

• 1:14:52Anna Lembke?

  in people over age sixty-five.

• 1:14:55Rich Roll?

  From when to when?

• 1:14:56Anna Lembke?

  Between the late nineteen nineties and today. And they've gone up eighty percent in women, which is a really fascinating change.

• 1:15:05Rich Roll?

  So what do you make of that?

• 1:15:07Anna Lembke?

  Well, it's complicated. First of all, for older people, what I make of it is that we are living longer, right? And that as people age and their brains age, a lot of folks who have been able to kind of moderate their use for most of their middle years are finding in their latter years that something changes biochemically, psychologically, and all of a sudden they pop off into addiction. I see these people all the time, people, you know, basically like baby boomers, right? It was like, I've smoked pot every day since I was twenty-five. I never had a problem. All of a sudden, I'm dabbing, right? And it's unmanageable. And that's in some ways harder because now you have, you know, sixty-five years of habit and learned experience around using every day.

• 1:15:52Anna Lembke?

  You're going to give that up when you're, you know, sixty-five, seventy. You have less brain plasticity to form new habits. So I think the older people phenomenon is both a function of just living longer. Having more time, maybe more boredom. And then also, the more potent drugs that we have now, the more variety, people slipping into addiction in older age. For women, it's really fascinating because, I mean, I see that all the time, where, you know, traditionally, the rates of addiction of men to women, the ratio's been like five to one.

• 1:16:23Rich Roll?

  Right.

• 1:16:23Anna Lembke?

  Five men to every one woman with addiction. Now, it's one to one in millennials. I mean, it's like the equal amounts. And I think, you know, I mean, I could speculate on why that is. And I guess I will speculate. I think that, you know, with the women's movement and, you know, more opportunity and more equality, I think there are trade offs, right? That the burden that comes with burdens that may be leading women into more addictive tendencies. Plus, you've got more potency and more variety.

• 1:16:57Rich Roll?

  Right, yeah, that's what came to mind for me immediately, like, just the proliferation of so many different drugs now and the potency of them.

• 1:17:07Anna Lembke?

  Yes, right.

• 1:17:08Rich Roll?

  Compared to what it was decades ago.

• 1:17:10Anna Lembke?

  And that's a big part of it. But I also think part of it is, you know, culturally, like, women weren't really supposed to imbibe. And now, like, that's not really, that those cultural mores aren't really there anymore. You know, for better and for worse.

• 1:17:27Rich Roll?

  Yeah, that's interesting. And how does that break down in terms of opioid addiction? Like, what percentage of that can be attributed to opioids?

• 1:17:38Anna Lembke?

  In terms of addiction to opioids, I don't know if we have consistent science on that. You know, some studies show that women are more likely to be addicted to opioids. Others, other studies show men. One thing we know for sure is that men are more likely to die from opioids. And that's sort of interesting and not entirely clear why that is. But I think in general, the rates break down to about 50/50.

• 1:18:06Rich Roll?

  Right, and then just in terms of addiction, you know, at large, like, in this spike that we're seeing in the rates of addiction, how much of that overall, what portion of that is opioid related?

• 1:18:20Anna Lembke?

  Well, if you look at the current drug overdose deaths, the majority involve some kind of opioid. Polypharmacy is the norm in drug overdose deaths, and in fact, what confers a lot of the risk is polypharmacy. So mixing a bunch of drugs together is a lot more dangerous than monotherapy. But a lot of times, people are taking a mixture of drugs and don't know it, right? Because a counterfeit pill that they think is a Xanax bar actually has fluaprazolam, a benzodiazepine designer drug, plus a little bit of fentanyl in it, and they don't know that that's what they're taking.

• 1:18:51Rich Roll?

  Wow.

• 1:18:52Anna Lembke?

  What did you ask me? Sorry.

• 1:18:55Rich Roll?

  Yeah, I'm just trying to get at, I want to kind of segue into the whole opioid crisis, because this is obviously an area of expertise for you. And as a foundational to that, like, just getting a sense of how big the opioid problem is and what percentage of addiction overall it kind of commandeers.

• 1:19:13Anna Lembke?

  Okay, so there's somewhere between 2 and 15 million Americans today addicted to opioids. Why is the range so large? Because the way that we do those surveys varies a lot. According to the National Survey of Drug Use and Health, it's about 2 million Americans addicted to opioids, with about 11 to 12 million Americans misusing prescription opioids. So slightly different misuse is not necessarily addiction. Addiction is crossing into, kind of crossing a threshold there. So, but on the outer range, you know, some studies who have included, for example, homeless

• 1:19:54Anna Lembke?

  populations or incarcerated populations, have gotten up to as high as 15 million Americans addicted to opioids. So it's by any count, millions of Americans either addicted to and/or misusing opioids. And then if you look at opioid-related overdose deaths, what you see is that they've essentially been rising steadily since the late 1990s. They seem to go down and plateau a little bit in 2018, but in 2020, they rose the biggest percentage they have in the last 20 years.

• 1:20:26Rich Roll?

  Is that pandemic-related?

• 1:20:28Anna Lembke?

  Yeah, we think it's pandemic-related. A combination of an ongoing potent drug supply, especially including fentanyl, which is 50 to 100 times more potent than morphine or heroin, combined with increased isolation and decreased access to treatment.

• 1:20:46Rich Roll?

  Right. So wild.

• 1:20:48Anna Lembke?

  Yeah.

• 1:20:49Rich Roll?

  So let's talk about how we got here. I mean, you wrote this other book, Drug Dealer M.D. It's a pretty fascinating dissection of the origins of the opioid crisis, how we got here, and the, you know, multiple contributing factors to it. Talk a little bit about that.

• 1:21:07Anna Lembke?

  Yeah.

• 1:21:08Rich Roll?

  The idea of Big Pharma and Big Medicine being in cahoots to, you know, create this problem that we're having such difficulty figuring out.

• 1:21:18Anna Lembke?

  Yeah, so in the early 2000s, I started seeing more and more patients coming in addicted to the opioids that their doctors were prescribing. And that was really at the beginning of my own personal reeducation around addiction and how to help people with addiction. And I learned so much from my patients and my colleagues about addiction medicine. And really, it transformed the way that I practiced. So I assumed that if I just educated my colleagues about addiction, they would all also see the light and stop prescribing in that way. And what I discovered was that even with reeducation, even when, for example, I consulted on a

• 1:21:59Anna Lembke?

  patient and let them know, "Oh, by the way, this person went to 10 other doctors in the same month to get Vicodin. You should stop prescribing for them." They didn't stop prescribing. And that was really the moment where I thought, "What is going on here? This is really bizarre. This is a really good person. This is a highly educated person. Why on earth are they continuing to prescribe in this way?" And what I then discovered through my research is all of the invisible incentives inside of medicine that keep doctors prescribing in ways that are orthogonal to patients actually getting better.

• 1:22:39Anna Lembke?

  And the most shocking discovery for me was the extent to which the opioid pharmaceutical industry had essentially infiltrated every aspect of medicine to promote opioid prescribing. And their influence was so enormous and so powerful that essentially doctors were...

• 1:22:58Anna Lembke?

  Not able to not prescribe. And the vehicles that pressured them into it were shame, basically saying, "Pain is undertreated, and the reason it's undertreated is because you are opioid-phobic, afraid of opioids, so you need to prescribe more." It was things like the Joint Commission creating guidelines and quality measures that said, "Every doctor has to ask every patient about pain, whether or not they look like they're in pain, and use this pain scale from 1 to 10, and prescribe opioids if they endorse pain." It was things like the Federation of State Medical Boards saying, "If you don't treat pain using opioids effectively, you're going to get sued, you're opening yourself up to a lawsuit." And behind all of those regulatory bodies and all of those professional medical societies

• 1:23:43Anna Lembke?

  were millions of pharmaceutical dollars.

• 1:23:46Rich Roll?

  Yeah, and in order to really understand this, you have to understand the history of how the medical establishment has thought about pain and what it means and how to treat it.

• 1:23:59Anna Lembke?

  Yeah, I mean, so, for example, the whole concept of chronic pain, pain that lasts every day for more than three months, three months being the time that we consider normal tissue healing should occur, that concept of chronic pain didn't even exist until like the middle of, you know, the 1900s. Prior to that, pain had been considered to be a downstream effect of a disease or an injury. The whole phenomenon of more and more people developing these chronic pain conditions, as well as the industry that goes along to treat it, is, you know, about 50 years old. And that industry, in effect, of course, in a way, has generated the pharmaceutical

• 1:24:42Anna Lembke?

  companies that now serve that cause, you know, to the extent that we have the opioid epidemic.

• 1:24:57Rich Roll?

  Right, so originally, pain was construed as something that potentially had benefits in terms of accelerating healing, or helping you to develop some kind of physical or emotional resiliency. At a certain point, the thinking shifted to, no, all pain is bad. It creates all kinds of trauma, and it should be ameliorated at all costs. Enter the pharmaceutical industry, and a whole infrastructure around making sure that nobody ever feels pain, ever, and demonizing any doctors who are not going to ensure that that patient walks out of the office armed with everything they need to never experience pain.

• 1:25:42Rich Roll?

  And that early idea proved to be untrue, right? And we're seeing the kind of waste byproduct of wrong-headedness.

• 1:25:51Anna Lembke?

  Yes, exactly. I mean, not only did it turn out to be untrue, but it turns out that taking opioids every day for long periods of time can actually make pain worse through this process of opioid-induced hyperalgesia, which is basically the pleasure-pain balance, neuro-adaptation, and changing set points around pain such that pain will get worse if you take an opioid every day to treat pain. And you're absolutely right. When, you know, in the middle 1800s, when general anesthesia was first invented, the leading surgeons in this country actually were resistant to using it because they felt like experiencing some amount of pain, you know, boosted the cardiovascular response,

• 1:26:35Anna Lembke?

  boosted the immune response, and it was good for tissue healing. Now, I don't know of any objective science showing that that's true, that pain actually expedites healing, but there are studies now showing that opioids can slow healing down.

• 1:26:49Rich Roll?

  Right, right. That's a shocking thing to realize, right?

• 1:26:53Anna Lembke?

  Yeah.

• 1:26:54Rich Roll?

  And much like the cigarette industry, the pharmaceutical industry put a lot of time, money, and effort into creating a narrative here. I think I read some, something about, there was a guy, what was his name, who was propagating this narrative that only 1% of people who were on opioids would develop some kind of addiction. And that became kind of like the trope that doctors would think. It became an entrenched kind of talking point.

• 1:27:22Anna Lembke?

  Yeah, so that basically started with Purdue's promotion of Oxycontin. In 1980, there was a letter to the editor, which doesn't count as a study. It's just like the equivalent of a medical journal tweet by two individuals called Porter and Jick, saying that in a cohort of 11,000 hospitalized patients, they only had four people who manifested signs and symptoms of opioid addiction. So in 11,000 patients who got opioids to treat their pain, only four of them got addicted, which comes out to less than 1% in that population. And that one tiny little data point, which is not really a study, was then used by Purdue

• 1:28:02Anna Lembke?

  Pharma in their promotion of Oxycontin to say, hey, if you're a doctor using opioids to treat a patient with pain, less than 1% of those individuals will get addicted to opioids. It turns out that is totally untrue. A meta-analysis by Volz et al., which came out around 2015, shows that 1 in 4 patients prescribed an opioid for a bona fide pain condition will develop an opioid use problem, and 1 in 10 will get severely addicted.

• 1:28:35Rich Roll?

  Wow.

• 1:28:36Anna Lembke?

  But those kinds of messages that addiction is rare, or uncommon, or few will get addicted, as long as you're a doctor and there are patient in pain, was really believed by most of the medical establishment through the first part of, you know, this century. And almost on like a magical biological level, like, there must be something magically protective biologically if a person has pain when you give them an opioid. Like, somehow that's gonna erase the addictive part, but it doesn't, it's not true. It doesn't work like that.

• 1:29:08Rich Roll?

  Right. So, you know, the conspiracy-minded person inside of me, you know, pictures the mustache twirling guy at the, you know, at the board meeting at, you know, pharmaceutical company X, getting on the phone with, you know, I don't know, you know, somebody at the FDA. Like, how does this all break down? Like, what's conspiracy and what's reality in terms of how the tectonic plates of medicine and pharmacy and government kind of created this situation that has produced the crisis that we're in?

• 1:29:42Anna Lembke?

  Well, I mean, I'm not sure I would use the word conspiracy to describe it, but what we definitely have is misleading promotion on the part of opioid manufacturers that represented as science what in fact was untrue messages about what opioids can and can't do, essentially overstating the benefit and understating the risk, in a very fertile ground of healthcare providers who wanted to believe it. Why did they want to believe it?

• 1:30:19Anna Lembke?

  Because medicine has transformed in the past 30 years into basically assembly line, production, quota, incentives. We have to get patients in and out, we have to do it quickly, we have to make sure that they're satisfied customers. When their insurance changes, we may never see them again, they'll see another doctor, there's a different doctor for every different body part. So, the misleading messages were also delivered to a population and institutions for which those were very convenient myths. And I think it's that combination, the intense lobbying, the intense promotion, the millions

• 1:31:00Anna Lembke?

  of dollars given to the FDA, the DEA, other regulatory bodies, you know, promoting these messages. And then you've got healthcare providers who frankly really want to believe them because they're seeing more and more patients with terrible and debilitating pain, for which they don't have the time or the energy or the resources to provide something like, you know, a plant-based diet as a way to get well, or even physical therapy, right? They've got to get them in and out the door.

• 1:31:25Rich Roll?

  Yeah, and then layer on top of that, the prospect of malpractice if you don't treat that pain, right? So you have this misalignment of incentives that create this problem.

• 1:31:36Anna Lembke?

  Yes, exactly.

• 1:31:37Rich Roll?

  Yeah. And the pernicious thing is that... This becomes the entry point for so many people who otherwise might have never experienced any form of addiction, right? And I know so many people in the program who end up relapsing because they go in for a knee surgery, or they have a back problem, or they've been sober for 20 years, and it takes them out.

• 1:32:00Anna Lembke?

  Yeah, no, it's terrible. So in the 1960s, if you asked somebody who was addicted to heroin what their first exposure to opioids was, 80% would say that it was heroin, right? They started with heroin as their first opioid. In the early part of this century or today, if you ask people who use heroin what was their first exposure, 80% of them will say it was a prescription opioid.

• 1:32:23Rich Roll?

  Right, yeah, that's crazy. So this spike in heroin use that we're seeing is really a function of opioid addiction.

• 1:32:30Anna Lembke?

  Prescription opioid addiction.

• 1:32:32Rich Roll?

  And when you've exploited all the doctors who will tolerate you and you've got nowhere else to go, you're going to find the heroin dealer.

• 1:32:38Anna Lembke?

  That's exactly right. That's exactly right. And then when that heroin supply has spiked with fentanyl, then you've got people who are, you know, who are dying because fentanyl is so much more potent.

• 1:32:47Rich Roll?

  Hmm. I know that you've testified on the Hill, you've spoken at the White House, you're involved in, you know, policy on some level. What's your sense of where we're at now with redressing this crisis?

• 1:33:01Anna Lembke?

  Well, I mean, just last week, I was in New York testifying in the first jury trial of this opioid litigation. And as you probably read in the paper today, there's a $26 billion settlement in the offing.

• 1:33:15Rich Roll?

  I didn't know that.

• 1:33:16Anna Lembke?

  Yeah.

• 1:33:17Rich Roll?

  Tell me about that. I was in New York, I would have come to the trial.

• 1:33:19Anna Lembke?

  Oh, okay, yeah. It was open to the public, so you could have come. Seven grueling days.

• 1:33:23Rich Roll?

  Yeah, tell me about this.

• 1:33:24Anna Lembke?

  Well, it was fascinating. So, I mean, first of all, the opioid litigation is understandably confusing to people because people think that the settlement with Purdue that happened, you know, some already, I think, last year, even though it's still evolving, is sort of the whole deal and the done deal. What they don't realize is that there's something called the multi-district litigation, which is essentially thousands of states and counties coming together to sue not

• 1:33:51Anna Lembke?

  Just Purdue and other opioid manufacturers, but also the distributors that truck the opioids from the manufacturer to the pharmacies and the pharmacies who have dispensed these opioids to the public, thereby creating what the lawyers call a public nuisance. And the idea of a public nuisance is just that the actions on the part of the opioid pharmaceutical industry led to and caused the opioid epidemic. So there have been a series of bellwether trials for the multi-district litigation that I've been involved in as a medical expert witness. I wrote a report, I've testified. But the trial in New York last week is the first jury trial that is trying this. And it started out with, I think, 11 defendants.

• 1:34:34Anna Lembke?

  And Johnson & Johnson settled, the distributors settled. So what's remaining is just a smattering of opioid manufacturers, not including Purdue, for example, which has declared bankruptcy. You can't sue somebody who's in bankruptcy. So it's a very-

• 1:34:48Rich Roll?

  Purdue behind OxyContin?

• 1:34:51Anna Lembke?

  Yes, so Purdue, yeah, Purdue is behind OxyContin. And they were sort of like the genius, so to speak, like the sort of malevolent genius behind marketing opioids in a way that would be extremely palatable to prescribers and would overstate the benefits and understate the risks. And then others copied them in suit. So what would be great is if there could be some kind of global settlement so that all these different county and state trials would come together and be a part of that global settlement so that the litigation could end. Because we can't keep trying this over and over again. And the good news is that it looks like

• 1:35:36Anna Lembke?

  a global settlement, this $26-plus billion, may actually be in the offing. It's not a done deal that all the different states and counties in the multi-district litigation have to agree to it. But hopefully, the details will be able to work out.

• 1:35:52Rich Roll?

  Sure. Yeah, because it's a settlement, it doesn't create some kind of case law precedent, but certainly a chilling effect, right? So what is the kind of implications of that settlement? And how does that impact how pharma thinks about this and moves forward?

• 1:36:08Anna Lembke?

  Oh, yes, I'm remembering that you have a law degree.

• 1:36:09Rich Roll?

  Yeah, sorry. It's been a while.

• 1:36:12Anna Lembke?

  No, no, it's good.

• 1:36:13Rich Roll?

  Since I flexed that muscle.

• 1:36:14Anna Lembke?

  So what's interesting is settlements are, and again, I'm not a lawyer, but this is what I've learned through this experience. So settlements can take many different forms. This settlement that's in the offing, importantly, the defendants are not admitting to wrongdoing, right? But they're providing money to abate the harms of the opioid epidemic. And one of the things that looks like will come out of it in terms of monitoring diversion, where basically pills going to people other than who was intended, is some external agency, which I think is really good, to monitor diversion. Because essentially, what we have now

• 1:36:57Anna Lembke?

  is that the opioid pharmaceutical industry is supposed to police itself. And that has not worked out very well.

• 1:37:06Rich Roll?

  It never does.

• 1:37:07Anna Lembke?

  No, it never does.

• 1:37:08Rich Roll?

  Just like big tech. I mean, the parallels here are unbelievable.

• 1:37:12Anna Lembke?

  Yes, yes, that's right. So one of the major things that looks like may come out of this settlement is a better policing system that is not the industry itself policing itself. But then also importantly, billions of dollars going to states and counties to do things like help treat opioid addiction. You know, that was, in the tobacco settlement, that was also what the money was intended for. Most of the money went to balancing state and county budgets and didn't end up going to people who had been harmed. So one of the things that people are trying to be very thoughtful about with this settlement is making sure that the money actually goes to the people that have been harmed. Importantly, this settlement does not include monies going to affected individuals and their families.

• 1:37:56Anna Lembke?

  It's a public nuisance claim. So it's going to states and counties to address the community, not individual claims.

• 1:38:06Rich Roll?

  It's interesting. So where does that money get spent ultimately?

• 1:38:10Anna Lembke?

  Yeah, great question. I mean, I think it's going to be budgeted at the state and county levels.

• 1:38:15Rich Roll?

  Right. Which means it's probably not going to get spent in an effective way.

• 1:38:20Anna Lembke?

  I hope that's not true. I hope that's not true. I'm trying to be optimistic. There are so many good and well-intentioned people, you know, involved in this process. And I really do hope that the money is put to good effect. I think it will be, I mean, not all of it, but I think much of it, you know, which brings up another point. One of the main ways that we as a society currently pay for addiction treatment is through grants from the federal government. And the reason that that's problematic is because by relying on these temporary grants, we never build an infrastructure inside of medicine to target

• 1:39:02Anna Lembke?

  and treat addiction, like the way we have excellence, like centers for cancer treatment, right? Or centers for diabetes treatment. What we need is addiction treatment centers, like right at Stanford University, right? Or whatever the hospital is, there should be a unit and there should be, you know, a specialized clinic building and inpatient beds. We don't have that. And so I do hope that this money will be put toward actually building the infrastructure that can be a part of, you know, the weft and weave of medical practice and not siloed outside of that.

• 1:39:40Rich Roll?

  Yeah. Hundred percent, we need better rehabilitation across the board. And that should be, especially with the opioid crisis and all the attention it's receiving, it should be something that would marshal the political will to create something that could be of greater benefit to those that suffer. I mean, it's such a, you know, on one level, kind of a no-brainer, right? This is what we should be doing. We shouldn't be putting these people in jail. We should be treating these people and rehabilitating them. At the same time, kind of big rehab, you know, if there is such a phrase, is rife with all kinds of crazy corruption and problems. There's a lot of predatory behavior, especially

• 1:40:25Rich Roll?

  in the kind of sober living ecosystem right now.

• 1:40:30Anna Lembke?

  Yeah, this is such a tough thing because I, as a treatment provider, am very grateful for the good residential facilities and the good sober living environments out there, without which some of my patients wouldn't have a hope. But you're absolutely right. We don't have adequate oversight. We don't have quality measures. We don't have good outcome data. I mean, we know treatment works and we know people get into recovery with or without treatment. So, I mean, there's a lot of reason for hope and optimism. But you're absolutely right. It's been siloed and marginalized in medicine, and so we have not gathered the data to really

• 1:41:13Anna Lembke?

  be able to guide building this infrastructure going forward, and we need to do that.

• 1:41:18Rich Roll?

  Yeah. One of the things that is unique to our time is the proliferation of certain types of pharmacology that have now been mainstreamed and legalized. So, we have pot essentially being legal now. It's ubiquitous. It's everywhere. You walk down the street in New York or Los Angeles, you can't help but smell it. There's dispensaries everywhere that look like the Apple Store. Billboards all over the place. At the same time, we have a lot of interesting science going into clinical applications for psychedelic compounds, and I think what's going on there is super interesting.

• 1:41:59Rich Roll?

  But for me, as somebody who's been in recovery for a long time, I, you know, these are like trigger points for me. It's like, oh, pot should be part of your wellness routine, or what ails you can be found in doing this mushroom trip under supervision. And I find this tension because on the one hand, it's like, no, I'm clean and sober, and this is what I do, versus, you know, people who I respect telling me, like, actually, you might find some benefit in exploring these things. And when you tell an addict that the solution to what ails them can be found in a mind-altering substance, that ends up renting a lot of space in my head.

• 1:42:40Rich Roll?

  So, walk me through how you think about this, you know, kind of cultural development that we're seeing right now.

• 1:42:47Anna Lembke?

  I have to admit that I am equally ambivalent. You know, as somebody who's been treating people with addiction, getting into recovery for going on more than 20 years, it is very hard for me to believe that a chronic, relapsing and remitting illness is going to be effectively treated by, you know, three doses of LSD or psilocybin or whatever it is. I just am very skeptical of that. On top of that, you know, I want to try to have an open mind about the potential utility of these agents in certain very rarefied conditions.

• 1:43:29Anna Lembke?

  But I think that overall, the messaging is very dangerous. Because exactly as you describe, I have many patients who have been in recovery and are doing well, who all of a sudden, you know, read a book that says that they could have some kind of spiritual awakening if they take ecstasy or they take psilocybin. And then that, as you say, they actually ruminate on it in the beginning. They think more and more. And then everybody else is doing it. And, you know, someone famous said that they did it. And, you know, it was so great. Then I've got a really big job, you know, there. First of all, I don't have a crystal ball. You know, I don't know what's going to happen to them. But my instinct, my experience

• 1:44:13Anna Lembke?

  and my knowledge of the science tells me that would not be a good thing.

• 1:44:16Rich Roll?

  Hmm.

• 1:44:17Anna Lembke?

  That would not be a good thing for somebody with the disease of addiction. And so, you know, then I have to like pull back from that and sort of say, well, you know, I hear you. But gee whiz, like, look at, look at the potential risks. And, you know, sometimes they listen and sometimes they don't. And the ones who don't, almost universally, end up in a very, very bad place. I had a patient who was in great recovery from his opioid use disorder, who got it into his head because of things that he had read, that he could treat his depression with ketamine. He ended up getting ketamine on the dark web, dosing it like every nine minutes for three days, ending up in the ICU with, I'm like,

• 1:44:58Rich Roll?

  Yeah, wow.

• 1:44:59Anna Lembke?

  Like irreversible neurological damage, irreversible in this PhD, brilliant PhD student who completely relied on his brain for, you know, his profession. And, you know, he's better now, but. Geez, like really?

• 1:45:14Rich Roll?

  And so was that person an addict in recovery at the time?

• 1:45:18Anna Lembke?

  Yeah.

• 1:45:18Rich Roll?

  Yeah, so you have a brain that is addicted. Like, you can't solve a problem with the brain that created it, right? So the lack of objectivity that you have. Because what part of that brain is truly seeking, you know, life improving solutions? And what part of that brain is the addict saying, "Oh, let's, we can find an excuse to go on this exploration."

• 1:45:40Anna Lembke?

  Right, yeah, especially when like brilliant, famous people are saying, "Oh, it opened my mind and I realized..."

• 1:45:46Rich Roll?

  You can justify it.

• 1:45:46Anna Lembke?

  Yeah, "I had a oneness and everything was so much better. And it's medicine, so you know, medicine, it's good."

• 1:45:53Rich Roll?

  The plant medicine.

• 1:45:54Anna Lembke?

  Yeah, right, right.

• 1:45:55Rich Roll?

  You know, if you call it medicine.

• 1:45:57Anna Lembke?

  Right.

• 1:45:58Rich Roll?

  You know, that's what's crazy. And it really does, like, it's weird. I mean, I had, you know, I love Gabor Maté. He told me after we did a podcast that he would personally, you know, supervise me in an ayahuasca experience, you know? I've got another friend who is a hardcore, you know, 12-step guy, been sober a really long time, leads meetings, helps lots of guys, did a supervised psilocybin experience. I think he did it at Johns Hopkins and just said it was revelatory. And I said, "Well, how does that impact how you think about your sobriety?" And he's like, "I'm not sure right now."

• 1:46:35Anna Lembke?

  Oh, God.

• 1:46:35Rich Roll?

  So it's confusing, it's destabilizing. You know, you hear one thing, you hear another thing. All I know is that I've stayed sober in a certain way for a long time and I'm very reluctant to screw with that. But I can't help thinking like, well, maybe I could have some kind of, you know, epiphany or psychological breakthrough that is unavailable to me, that could be helpful. Is that a rationalization? Is that a justification? Or is there some truth to that?

• 1:47:07Anna Lembke?

  So here's the thing. You already had a spiritual awakening and you did it by hitting bottom and crawling your way back out again. That took time. It took an incredible amount of tolerating pain and it led to really good things.

• 1:47:25Anna Lembke?

  I do not believe that there is a pill that you can take or a substance that you can imbibe one time or two times or three times that can buy you that. It can maybe give you a shadow version of that, but not in the deeply embedded neurological way that is necessary for sustained wellness and recovery. What people want is the spiritual awakening without doing the hard work to get there. You know, one of my patients once said to me, "One of the things that I've learned about addiction and recovery is the hard way is usually the right way." And to me, these psychedelic interventions, they're like taking the gondola to the top of the mountain

• 1:48:10Anna Lembke?

  instead of walking up. Now, you could argue that, okay, you know, both people got to the top of the mountain, but I contend that there's something more enduring and better about walking up to that top of the mountain than taking the gondola. Now, and again, I admit I'm probably biased from 20-plus years of, you know, treating people in recovery. And, you know, maybe there are aspects of my personality that I also bring to the table that will always kind of favor, let's say, a more ascetic approach to life. But I just, I find it hard to believe, you know, that there's not a cost to pay on the other side.

• 1:48:54Rich Roll?

  Yeah, I appreciate that. I mean, I don't know a lot of people who are walking the earth enlightened as a result of this, if it was really delivering on the promise. And I think, you know, it's just interesting to see the kind of cultural embrace of this and the vernacular that goes into it, whether it's, you know, pot or ayahuasca, the plant medicine, or this is, you know, this is, you know, life-enhancing as opposed to detrimental. Like, particularly with pot and as a parent of teenagers, you know, the way in which it's messaged, you would think that this is innocuous and that everybody's life would be better with a little bit of this.

• 1:49:34Anna Lembke?

  Right.

• 1:49:34Rich Roll?

  But for every, you know, Seth Rogen, there's a lot of damage that I think... You know, is underappreciated and not talked enough about. Like, I know plenty of people in recovery whose drug of choice is marijuana. And it's, you know, it's far from innocuous.

• 1:49:51Anna Lembke?

  Yeah, and again, I think what I, what I try to communicate to people, because I think it's underappreciated, is you might be fine smoking pot every day for 10 years, 20 years, maybe even 30 years, but eventually it will come and bite you in the butt. And then it's going to be really, really ugly. So why not stop now? Why not stop now?

• 1:50:13Rich Roll?

  My mind is like, well, I'll deal with that in 30 years. If I can do this for 30 years without a problem, like, sign me up for that.

• 1:50:19Anna Lembke?

  Really? Because in 30 years, I mean, it's really, really bad. Do you know what I mean? And also, I think it's even in those 30 years, it's deceptive. Because basically, you develop tolerance, your brain adapts. And then you're using to stave off withdrawal from the last dose. You're not really feeling better anymore. I mean, it's that deceptive piece.

• 1:50:40Rich Roll?

  Right, you just need it to feel normal.

• 1:50:42Anna Lembke?

  Right, and that not, you're not really seeing the impact because you're in it.

• 1:50:46Rich Roll?

  And I suspect that somebody who's been a chronic daily pot smoker for 30 years, when they do decide enough's enough and they try to stop, that period of acclimating your neurochemistry to some level of normal is going to be brutal and very long.

• 1:51:03Anna Lembke?

  Brutal, long, and in some, in some cases, not possible. Right? I especially have a cohort of older adults who've been smoking pot their whole lives, who actually, they've lost the brain plasticity to adapt to not using. And yet, not only is the pot not working for them anymore, it's actually turned on them, gives them panic attacks, makes them paranoid. So here's this thing that they have to keep using every day in order to stave off withdrawal, but it makes them feel absolutely awful. So that's what I mean about the cost.

• 1:51:37Rich Roll?

  What about vaping?

• 1:51:39Anna Lembke?

  Vaping nicotine, vaping cannabis?

• 1:51:41Rich Roll?

  I guess you can vape anything now, right?

• 1:51:43Anna Lembke?

  You can really vape anything, right?

• 1:51:44Rich Roll?

  I mean, I know very little about this, other than the fact that I'm a parent of teenagers and this is like a huge thing.

• 1:51:49Anna Lembke?

  Yes.

• 1:51:50Rich Roll?

  The fact that not only are powerful substances more readily available, they've suddenly become essentially undetectable.

• 1:51:58Anna Lembke?

  Right, they're like little chargers, right.

• 1:52:00Rich Roll?

  There are kids that vape in the classroom. They know how to do it while they're sitting in class and not be detected by the teacher.

• 1:52:06Anna Lembke?

  Right, it's odorless. It does create a kind of a smoke, but you know, it's not the kind of smoke that you would get with cigarettes. It looks like a little battery charger. You can just, you know, plug it into your computer, so it's essentially undetectable. And the scary thing especially about the nicotine pods is that they deliver so much nicotine that kids are ending up with very high blood levels of nicotine, much higher than they would with normal cigarettes. So these kids aren't sleeping, you know, they're jittery. Yeah, I mean, the technology has made these things so potent and so accessible that it's really scary.

• 1:52:44Rich Roll?

  Are you seeing this show up in your patients in the clinic? In your clinic?

• 1:52:48Anna Lembke?

  We are seeing a lot of that. It's funny, in the Bay Area, parents and other advocacy groups mobilized very early to raise awareness about vape pens and, you know, nicotine levels. So we've done a lot of community education around this, such that we were initially seeing a ton of vaping and I feel like it's dropped off a little bit. What we really struggle with, frankly, most in young people is cannabis.

• 1:53:16Rich Roll?

  Yeah. I want to spend the last section of this talking about how to identify somebody who is potentially addicted or is moving in that direction. Like, what are some of the warning signs? Whether you're a parent, or a friend, or a brother, or a colleague, given the ubiquitous nature with which we're all becoming addicted in this diversity of ways? Like, what are some of the warning signs?

• 1:53:49Anna Lembke?

  I think one of the most important warning signs is the double life, which is when we're...

• 1:53:58Anna Lembke?

  Behaving one way with the people in our lives and then have this separate life that they're not aware of and that we lie about. To me, that's a really important early sentinel signal that indicates a whole host of different types of compulsive overconsumption edging toward addiction. So, believe it or not, I actually prescribe truth telling to my patients, no matter what stage of their addiction they're in, even people with little minor addictions. I say, "Try to go this whole month and don't lie about what you're using, but also don't lie about anything at all."

• 1:54:37Rich Roll?

  Right.

• 1:54:37Anna Lembke?

  Which turns out to be really, really hard for all of us.

• 1:54:40Rich Roll?

  Yeah, and terrifying.

• 1:54:40Anna Lembke?

  Yeah, and terrifying, because we're all liars. It's a sort of part of human nature. So I think that's a piece of it. Often you'll hear people who are in my field tell parents that you should look for changes in function. But unfortunately, there are a lot of kids who can be using a lot of drugs and get straight A's and appear to function just fine.

• 1:55:07Rich Roll?

  It may improve their function.

• 1:55:08Anna Lembke?

  Right.

• 1:55:09Rich Roll?

  In many cases, it does.

• 1:55:10Anna Lembke?

  Exactly. Well, that's right.

• 1:55:11Rich Roll?

  All's well.

• 1:55:12Anna Lembke?

  Yeah, it solves a problem, whether that's anxiety or social phobia, wanting to be comfortable in groups, or manage anger, or existential uncomfortableness, or whatever it is. So I don't really think that function, per se, is necessarily going to allow us to detect that in our loved ones. I really think that this kind of, you know, obfus- I can't even say the word.

• 1:55:42Rich Roll?

  Obfuscation.

• 1:55:43Anna Lembke?

  Thank you, obfuscation. This sort of smoke and mirrors. Even little things like saying, "Oh, I was over there, but then you weren't there, you were somewhere else." That should be a worry. That should be a worry.

• 1:55:59Anna Lembke?

  Yeah, I guess that's, I mean, you know, I don't like to say like, oh, look for this, because the truth is that people are really good at covering up addictive behaviors.

• 1:56:08Rich Roll?

  Yeah, that's what I was thinking. Like, you can say, well, you know, look for the double life, but the addict is very diligent and crafty in protecting that second life to be undetectable.

• 1:56:20Anna Lembke?

  That's exactly right.

• 1:56:21Rich Roll?

  So when you, when they come into your clinic and are at some level of being ready to be honest, that doesn't mean that they're going to be ready to be honest outside of your office.

• 1:56:29Anna Lembke?

  That's for damn sure.

• 1:56:31Rich Roll?

  Yeah.

• 1:56:32Anna Lembke?

  Boy, I just had a patient last week and I, we even role-played about how she was going to tell her girlfriend that she relapsed and I said, okay, call me tonight and let me know how it went. No phone call.

• 1:56:43Rich Roll?

  No phone call.

• 1:56:44Anna Lembke?

  No phone call.

• 1:56:44Rich Roll?

  Yeah, but you've been doing this long enough to know that on some level, perhaps you weren't expecting a phone call.

• 1:56:50Anna Lembke?

  Oh, I always hope for it. I always hope for it. Because sometimes, sometimes, you know, it works and I get the phone call. So, so I always expect it, hope for it, but and yet I'm not surprised when I don't get it. And I'll just have to reach out to her again and keep holding her in that space till she's, she's ready. Keep encouraging her to make that step. But yeah, I mean, it's, it's hard. And I, you know, I really feel for parents because many times when serious addictions come to light, parents blame themselves and say, how could I not have seen that? How could I not have known? And I just feel like saying, like, easily, you could not have known very easily because, you know, people are really good at hiding these behaviors and come up with all sorts

• 1:57:34Anna Lembke?

  of really advanced strategies for doing it. So, you know, don't blame yourself. I mean, I don't know what my kids are doing online. I mean, you know, now that they're older, I did when they were younger. Now I have no idea. And I'm kind of neurotic about it too. But what I try to do is educate them about the pleasure paying balance and really demand honesty. I say, you know, I can't control what you do, but don't lie to me.

• 1:58:01Rich Roll?

  It's a hard balance to strike as a parent. You don't want to be the overly intrusive, overly helicoptering parent who's into their business too much, but you also can't be checked out either. And where that sweet spot is, is very difficult.

• 1:58:19Anna Lembke?

  You know, it's interesting. Data show that parents who are more involved in their kids' lives, know where their kids are, know their friends, check their backpacks, go through their rooms, that those kids are actually at decreased risk of developing addiction.

• 1:58:39Rich Roll?

  Yeah, it's not surprising.

• 1:58:40Anna Lembke?

  Now, I agree with you. There is a quality to that, that if it's intrusive and overly controlling, can completely backfire.

• 1:58:48Rich Roll?

  Yeah, that will create the opposite reaction, once they get a little freedom.

• 1:58:52Anna Lembke?

  Yes, and lord knows, I've been guilty of that in my own.

• 1:58:55Rich Roll?

  And that's my story.

• 1:58:56Anna Lembke?

  Is that your parenting story too?

• 1:58:57Rich Roll?

  Well, it's, no, it's my childhood story.

• 1:59:00Anna Lembke?

  Oh, interesting. Okay. Interesting. Yeah, okay, so how did that go, so I can not make that mistake?

• 1:59:05Rich Roll?

  Well, I just, I grew up in a, I mean, you read my book. I grew up in a very achievement-oriented household, and there was a lot of attention on me and a lot of expectations. And I was very academically and athletically motivated, but I lived a very structured life. Like, I never got into trouble, I never broke the rules or any of that kind of stuff. And when I moved 3,000 miles, like, no wonder I moved 3,000 miles away to college. When I was able to put that kind of distance between my upbringing and my current situation, I found myself spinning out of control, or just sowing my wild oats in a way that was unhealthy, because I think there wasn't enough freedom that I had.

• 1:59:49Rich Roll?

  And it was, not to overly blame my parents, like, a lot of it was self-imposed.

• 1:59:54Anna Lembke?

  Yeah, so I hear you on that, but I'm wondering, what could your parents have done differently that might have protected you?

• 2:00:01Rich Roll?

  Hmm, that's a good question. Maybe nothing, or maybe just...

• 2:00:09Rich Roll?

  Creating a little bit more leeway to kind of get in trouble a couple of times, you know, because I was so afraid of getting in trouble.

• 2:00:18Anna Lembke?

  Yeah.

• 2:00:18Rich Roll?

  So that I could have gotten a little bit of that out of my system, or just had that experience younger.

• 2:00:26Anna Lembke?

  Yeah. Well, I'm going to think about that.

• 2:00:29Rich Roll?

  Yeah.

• 2:00:30Anna Lembke?

  I, you know, I'm, so addiction runs in my family and, you know, I am worried about our kids, particularly our sons. And, you know, I've tried to be real thoughtful as a parent around, around this to try and give them the best chance, you know, knowing that there are no guarantees. And I don't know that I've threaded the needle. I mean, I know, I know times when I've done it wrong and been sort of overly intrusive. And that kind of letting go is something that I'm working hard on now. I try to give them knowledge of the science,

• 2:01:13Anna Lembke?

  knowledge of people's life experiences, and also some metacognitive strategies along the lines of tell the truth. You know, that shame can be both a force for good and a force for evil. Think about quantity, frequency, potency. I mean, all the things I write about in my book. But still, I think that what you're saying about your childhood is probably true for my kids, you know, in an achievement oriented. So achievement can be its own addiction. That's the other thing, right?

• 2:01:47Rich Roll?

  Yeah, certainly, for me.

• 2:01:48Anna Lembke?

  Yeah. Well, I think for, for many of us. So, and so I, like, I wonder if our kids, you know, if they developed a problem. I hope that they would come to me and to us, but I do worry that they might not, because the shame would be so great. So anyway.

• 2:02:05Rich Roll?

  Right. And you being an expert in the field would, you know, multiply that.

• 2:02:09Anna Lembke?

  Right.

• 2:02:09Rich Roll?

  Possibly.

• 2:02:10Anna Lembke?

  Right. I think one of the things I've tried hard to do as a parent, and I'm curious about you, is that I've tried to be very open with my kids about my character defects and my mistakes, so that they know that I'm not perfect. Of course, they don't think I'm perfect at all. In fact, there's almost nothing good about me these days.

• 2:02:32Rich Roll?

  Yeah, I know what that's like.

• 2:02:34Anna Lembke?

  Right. But what I'm trying to say is, from very early on, I talked a lot about my mistakes, and my regrets, and my shame, and the bad things that I've done, and tried to own up, even in our interpersonal relationships, in the ways that I'm highly flawed and unbroken. I hope that will be helpful to my kids, to give them room to feel like, you know, we all make mistakes.

• 2:02:59Rich Roll?

  Yeah, I think that that's true. I think that's powerful. I mean, that's something that we've definitely practiced as parents. You know, and I've taken my kids to AA meetings, and they know my story, and we're pretty transparent, almost to a fault.

• 2:03:13Anna Lembke?

  Yeah, right.

• 2:03:14Rich Roll?

  When it comes to that kind of thing. Because that's how I'm inculcated in that. Like, that's my nature. Like, I don't carry shame around it anymore, and I'm fine talking about it. But what's interesting, at least with respect to our younger kids, we have one who is very extroverted and honest to a fault. Like, the great thing is, is like, she'll just tell you everything. And sometimes it's shocking.

• 2:03:40Anna Lembke?

  Right.

• 2:03:41Rich Roll?

  But, and if and when she does lie, like, she's a terrible liar. But she really is honest, and that's great. So there's an open channel there.

• 2:03:51Anna Lembke?

  Yeah, nice.

• 2:03:52Rich Roll?

  The younger one is very internalized. And so it's harder to know what's going on. And that's just their natural disposition.

• 2:03:59Anna Lembke?

  That's right.

• 2:04:00Rich Roll?

  So it's also an individual thing, with respect to what works for what kid.

• 2:04:05Anna Lembke?

  Yes, that's right.

• 2:04:06Rich Roll?

  Which makes it harder, I guess.

• 2:04:07Anna Lembke?

  Yes. Just when you think you've figured it out, you get a kid who doesn't work for another one. That's right.

• 2:04:13Rich Roll?

  I know. But it sounds like you've done everything that you can do. You're the psychi- you're the expert.

• 2:04:18Anna Lembke?

  I know, I know. That's the scary part, right?

• 2:04:22Rich Roll?

  And if something were to happen, you know, the job for you then, as you know, is like, it's not your fault. And I think this is something, you know, a lot of parents, like, I know my parents, like, when I ended up in treatment, like, they blamed themselves. They were devastated. And they kept running this... You know, narrative in their head, like, what did we do? And how did we cause this and all of that? And a lot of my work with them has been trying to alleviate that.

• 2:04:48Anna Lembke?

  Right. Yeah, I mean, I think it's perfectly possible that I'm doing something terribly wrong right now in my parenting that I will not realize until 20 years from now.

• 2:04:59Rich Roll?

  Right, well, I feel like it's rigged that way. Like, no matter what you do, it turns out to be the wrong thing.

• 2:05:04Anna Lembke?

  Right, right. But I think, I mean, one of the mantras that I've just sort of, I mean, I could almost get a tattoo for it, is the AA mantra, one day at a time, which I think is just such a healthy way to be a parent. Because all I can do is just try my best today to be honest and thoughtful, to listen, to really listen, to try to be helpful, to be a guide, knowing I'm probably going to make a lot of mistakes, but I'm trying, you know? I haven't given up, I'm in it, I'm trying. And I think, I think the kids can feel that, you know?

• 2:05:48Anna Lembke?

  That like, I want to be a good parent. I may not always be a good parent, but I'm trying to be a good parent. And I think that might carry me over and like, you know, help through some of the messed up stuff that I am sure that I'm doing.

• 2:06:04Rich Roll?

  Yeah. But in the event that one of them develops some kind of addiction situation, you know, sort of having a healthy relationship with how you contributed or didn't contribute to that while maintaining an open channel of communication, right? Isn't that the key?

• 2:06:20Anna Lembke?

  Yes, I think that's right. You don't want to take on too much responsibility. And this is where like the let it go, let it God is really useful. It's like, you know, I've done what I can do and now these are your choices, right? And kind of just saying like, this is your life, like.

• 2:06:35Rich Roll?

  Yeah.

• 2:06:36Anna Lembke?

  I think that's important.

• 2:06:37Rich Roll?

  And the genetic piece is interesting. Like, is it true or not? Like, there's this trope that it jumps generations. Like, my parents weren't alcoholics, my grandparents weren't either, but so you have... It's in your family. It's not in your generation. But is there this thing where it jumps generations? Is that a truism or is that not backed up by science?

• 2:06:58Anna Lembke?

  I don't think there's data to support that. The data are, you know, looking at family studies and twin studies. You know, an identical twin with an alcohol use problem will or an identical twin, if their twin has an alcohol problem, they're at higher risk. If you have a biological parent or grandparent. So it can skip the generations, but the biological parent, you know, is going to make a difference too. That's what the studies show. But I also just think, you know, again, addiction is endemic in the population. It's part of how we're wired. We are wired to seek out pleasure. We wouldn't be here if that weren't true. And so, you know, it can pop up anywhere.

• 2:07:40Anna Lembke?

  Like, you don't have to have it in your family for your kid to develop a serious addiction problem. And it doesn't mean that you did anything wrong or that there was trauma that needs to be uncovered. Right? It's just, it's like wiring.

• 2:07:52Rich Roll?

  Yeah. What about the epigenetic piece? This stuff is fascinating, right? The idea that your great-great-grandparent suffered some trauma in childhood and the emotional experience of that trauma gets passed down genetically and can manifest in some kind of unhealthy addiction-related behavior.

• 2:08:13Anna Lembke?

  Yeah, and I know there are animal studies showing that, you know, these non-inherited base pairs that get modulated through an experience. Literally that DNA then gets passed to, you know, the offspring and their offspring. So I guess all of that is plausible in humans as well. But, you know, I also wonder how much of it is just the culture. I mean, we inherit and elaborate on our culture as much as we do on our DNA. So I think it's going to be really hard scientifically to separate out what is like protein expression

• 2:08:55Anna Lembke?

  and what is, oh, this is how we do it in our family. You know, we talk about X, but we don't talk about Y. Or, you know, this is how you tolerate hard things that come along.

• 2:09:08Rich Roll?

  Yeah. Yeah. How can you parse those two things? It's almost impossible.

• 2:09:12Anna Lembke?

  I think almost impossible. Yeah.

• 2:09:14Rich Roll?

  Well, finding ourselves mired in a, in a culture that is driving us all towards some addiction in one form or another, maybe a good way to end this is to share, you know, a little bit of wisdom or some thoughts for the person who's listening, who's, who's never thought of themselves in any kind of addictive context, but is like, yeah, maybe I spend a little bit too much time shopping online, or, you know, I am sitting on the toilet a little bit too long scrolling through Instagram, or like, why is TikTok like, why can't I stop scrolling up on these TikTok videos? Or whatever it is.

• 2:09:48Anna Lembke?

  You know, my first intervention with most of my patients in my clinic, whether they come in specifically for a problem related to addiction, or whether they come in for something else like depression and anxiety, but are simultaneously consuming a lot of high dopamine substances or behaviors, is to recommend a dopamine fast. And that is a period of time abstaining from that drug or that behavior that is causing the problem or related to the problem. And over, you know, the last 20 years, I've essentially evolved an intervention, which is a month-long dopamine fast. The month is somewhat informed by the science. And there are some interesting studies that I talk about in my book.

• 2:10:31Anna Lembke?

  But essentially, I tell people, you know, you're going to go into withdrawal in the first two weeks. And by week four, you'll probably be feeling better as the gremlins hop off the pain side and homeostasis is restored, and you've generated more of your own dopamine. You're not as fixated on that drug and you're able to kind of get pleasure from more modest rewards. A lot of times, patients will ask, well, why can't I just reduce the amount? And the reason I don't recommend that is because it just usually doesn't work. We really need to reset reward pathways. And then if we decide to go back to using our drug in moderation, put barriers in place so that we can maintain moderation.

• 2:11:12Anna Lembke?

  And by the way, most of my patients who come in with even serious addictions, after a month of abstaining and feeling better, when I ask them, wow, things are so much better. Do you want to do another month? Or do you want to go back to using your drug? In the vast majority of cases, they want to go back to using, but they want to use less. So then we talk about barriers and, you know, how they can. Engage in what I call self-binding strategies and other metacognitive strategies to moderate use. And then it really is an experiment. Some people are able to moderate their use and others are not. And it's just like data gathering. Sometimes people can moderate their use and then decide it's just not worth it. Like it's so exhausting to moderate use that it's just easier to abstain.

• 2:11:54Rich Roll?

  Yeah. For me, abstinence is easier than moderating use.

• 2:11:58Anna Lembke?

  Yes, exactly.

• 2:11:59Rich Roll?

  You know, just remove it completely and eventually you acclimate. But moderating use ends up occupying a lot of emotional angst and mental energy.

• 2:12:08Anna Lembke?

  Yes, that's right.

• 2:12:08Rich Roll?

  But that's me, right? So that idea of abstinence followed by an experiment of what reframing your use looks like will be information that will tell you how big of a problem this really is for you.

• 2:12:22Anna Lembke?

  That's exactly right. It's informative in many different ways. And because it resets dopamine, it's also restorative because people tend to feel better after a month of that. And it gives you some guidance for, you know, what the next step might be, whether it's moderation or abstinence. I think talking about moderation, which has kind of been taboo in addiction medicine for many years, is also really important, not only because for some people moderation is actually the right choice, but because now there are so many drugs that, like, we can't eliminate entirely, like our smartphones. I mean, people, you basically can't function without a smartphone.

• 2:13:02Rich Roll?

  Or food.

• 2:13:03Anna Lembke?

  Or food, right? So then people have to figure out ways to moderate consumption of those substances or those goods. So it's an important discussion that we have to have. And my main message about self-binding strategies is that you have to think of them and put them in place before you're exposed to the substance. If you wait until you're offered, you know, a use, it's not going to work.

• 2:13:24Rich Roll?

  Forget it.

• 2:13:25Anna Lembke?

  Yeah, forget it. You have to anticipate it, have that barrier in place, have a plan. And you know, as I talk about again in the book, there are pharmacologic strategies now that can create barriers for people which are very interesting, things like naltrexone that blocks and binds and blocks the opioid receptor, that for some people is really a miracle drug when it comes to things like alcohol and moderating alcohol use. So there's an interesting, you know, science that's opening up there around ways to do that.

• 2:13:53Rich Roll?

  Yeah, the self-binding thing is interesting. I mean, basically, it's about prophylaxis, like creating space, like temporal, you know, geographic space, like all these different ways of, you know, putting distance between you and whatever the trigger is. But in the kind of vernacular of recovery, the idea being like, if you haven't done that, when you're met with that triggering substance, you're, it's going to be impossible to refuse it.

• 2:14:19Anna Lembke?

  That's right.

• 2:14:19Rich Roll?

  Because the train pulled out of the station a long time ago.

• 2:14:22Anna Lembke?

  Right.

• 2:14:22Rich Roll?

  Like that relapse was a long time in the making.

• 2:14:24Anna Lembke?

  Right.

• 2:14:25Rich Roll?

  And all it needed was an opportunity to express itself. And I think that that's underappreciated in, in thinking about recovery. Like, they always say, you know, in the rooms, like, you know, every decision, you know, everything that you do is either moving you, you know, towards the drug or away from the drug. And, and, you know, relapse often requires a very long runway.

• 2:14:47Anna Lembke?

  Yes.

• 2:14:48Rich Roll?

  And so being aware of that, like, it's, you know, what I'm doing now, today, to take care of my sobriety has an impact on, you know, some situation that I'll find myself in a month ago.

• 2:14:57Anna Lembke?

  Right.

• 2:14:58Rich Roll?

  A month later.

• 2:14:59Anna Lembke?

  Right, right, yes. I mean, in the throes of desire, there's no choosing. And the other important part of what you just said is that, you know, wellness is usually not one sledgehammer that's going to fix everything. It's the slow accumulation of a lot of small behaviors over many days. And that's something that I have to remind patients of again and again.

• 2:15:28Rich Roll?

  Yeah, in the book, you lay it out with this dopamine acronym, where every letter in the word dopamine is kind of one step along this pathway of thinking more intelligently about how all of this operates.

• 2:15:43Anna Lembke?

  Yes.

• 2:15:44Rich Roll?

  Yeah, cool. Well, it was awesome talking to you.

• 2:15:47Anna Lembke?

  Really awesome to talk to you. Thank you so much.

• 2:15:49Rich Roll?

  How do you feel? Did we do it?

• 2:15:50Anna Lembke?

  You know what?

• 2:15:51Rich Roll?

  Is there anything we didn't talk about?

• 2:15:53Anna Lembke?

  I am not worthy, because, no, I'm not blowing sunshine on you. I'm telling you the truth. Like, you read my book, you thought about it, you had, you got it, you asked great questions. Like, this has been the most satisfying

• 2:16:08Anna Lembke?

  interaction I've had around the book since I wrote it. And as an author, you know, like, the primary desire is to be understood. Like, we want to be understood. And I'm so grateful, because you get it, you totally get it, you got it, you get it. And it's been really rewarding talking to you because of that.

• 2:16:27Rich Roll?

  Well, I appreciate that. I want to come and have a therapeutic session in your office next time in the Bay Area.

• 2:16:32Anna Lembke?

  Anytime, free of charge.

• 2:16:34Rich Roll?

  Yeah, and I'd love to have you back on. Like, this is, obviously, as I said at the outset, this subject is near and dear to me. And I think, you know, we can't do it justice in a couple hours. So I'd love to continue the conversation.

• 2:16:46Anna Lembke?

  Oh, well, thank you. Yeah, no, I'd love to. And you know, especially, like, one of, it's so funny that you mentioned, like, Johann Hari and Gabor Maté, you know, two wonderful people. They've written wonderful books. But you drilled down to something. One of the reasons that I wanted to write this book was exactly that. It's like, yes, trauma's important, yes, social connection is important. But like, even without those problems, like, addiction is, you know, happens.

• 2:17:11Rich Roll?

  Yeah, it's still there.

• 2:17:12Anna Lembke?

  It's still there, and it can happen to any of us. And this problem of, you know, living in an addictogenic universe is really core now. Like, we have to realize that, because otherwise, we keep looking for the trauma, you know, or keep trying to like, well, maybe I'm not connected enough.

• 2:17:28Rich Roll?

  If we just understand that trauma, then...

• 2:17:30Anna Lembke?

  Right, if we just understand trauma, or if I just had a more intimate relationship with my spouse. And I, it's like, no, no, you could have the best relationship on the planet.

• 2:17:39Rich Roll?

  That's an emotional geographic, right?

• 2:17:42Anna Lembke?

  Right, yes. That's good. I've not heard that before. That's a good one.

• 2:17:45Rich Roll?

  All right, well, to be continued. In the meantime, everybody pick up Dopamine Nation. I love this book. I think it's going to help a lot of people. So thank you for the work that you do.

• 2:17:52Anna Lembke?

  Yeah, thank you.

• 2:17:53Rich Roll?

  And I'm at your service. Peace.

• 2:17:57Anna Lembke?

  And plants.

• 2:17:58Rich Roll?

  Sobriety.

• 2:18:00Anna Lembke?

  Awesome.

• 2:18:12Rich Roll?

  Thanks for listening, everybody. For links and resources related to everything discussed today, visit the show notes on the episode page at richroll.com. If you'd like to support the podcast, the easiest and most impactful thing you can do is to subscribe to the show on Apple Podcasts, on Spotify, and on YouTube. Sharing the show or your favorite episode with friends or on social media is, of course, always appreciated. And finally, for podcast updates, special offers on books, the meal planner, and other subjects, subscribe to our newsletter, which you can find on the footer of any page on richroll.com. Today's show was produced and engineered by Jason Camiolo. The video edition of the podcast was created by Blake Curtis.

• 2:18:55Rich Roll?

  Portraits by Ally Rogers and Davy Greenberg. Graphic elements courtesy of Jessica Miranda. Copyrighting by Georgia Whaley. And our theme music was created by Tyler Pyatt, Trapper Pyatt, and Harry Mathis. You can find me at richroll.com or on Instagram and Twitter at Rich Roll. I appreciate the love. I love the support. I don't take your attention for granted. Thank you for listening. See you back here soon. Peace. Plants. Amaste.